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entitled 'Recovering Servicemembers and Veterans: Sustained Leadership
Attention and Systematic Oversight Needed to Resolve Persistent
Problems Affecting Care and Benefits' which was released on November
16, 2012.
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United States Government Accountability Office:
GAO:
Report to Congressional Committees:
November 2012:
Recovering Servicemembers and Veterans:
Sustained Leadership Attention and Systematic Oversight Needed to
Resolve Persistent Problems Affecting Care and Benefits:
GAO-13-5:
GAO Highlights:
Highlights of GAO-13-5, a report to congressional committees.
Why GAO Did This Study:
The National Defense Authorization Act for Fiscal Year 2008 required
DOD and VA to jointly develop and implement policy on the care,
management, and transition of recovering servicemembers. It also
required GAO to report on DOD’s and VA’s progress in addressing these
requirements. This report specifically examines (1) the extent to
which DOD and VA have resolved persistent problems facing recovering
servicemembers and veterans as they navigate the recovery care
continuum, and (2) the reasons DOD and VA leadership have not been
able to fully resolve any remaining problems. To address these
objectives, GAO visited 11 DOD and VA medical facilities selected for
population size and range of available resources and met with
servicemembers and veterans to identify problems they continue to
face. GAO also reviewed documents related to specific DOD and VA
programs that assist recovering servicemembers and veterans and
interviewed the leadership and staff of these programs to determine
why problems have not been fully resolved.
What GAO Found:
Deficiencies exposed at Walter Reed Army Medical Center in 2007 served
as a catalyst compelling the Departments of Defense (DOD) and Veterans
Affairs (VA) to address a host of problems for wounded, ill, and
injured servicemembers and veterans as they navigate through the
recovery care continuum. This continuum extends from acute medical
treatment and stabilization, through rehabilitation to reintegration,
either back to active duty or to the civilian community as a veteran.
In spite of 5 years of departmental efforts, recovering servicemembers
and veterans are still facing problems with this process and may not
be getting the services they need. Key departmental efforts included
the creation or modification of various care coordination and case
management programs, including the military services’ wounded warrior
programs. However, these programs are not always accessible to those
who need them due to the inconsistent methods, such as referrals, used
to identify potentially eligible servicemembers, as well as
inconsistent eligibility criteria across the military services’
wounded warrior programs. The departments also jointly established an
integrated disability evaluation system to expedite the delivery of
benefits to servicemembers. However, processing times for disability
determinations under the new system have increased since 2007,
resulting in lengthy wait times that limit servicemembers’ ability to
plan for their future. Finally, despite years of incremental efforts,
DOD and VA have yet to develop sufficient capabilities for
electronically sharing complete health records, which potentially
delays servicemembers’ receipt of coordinated care and benefits as
they transition from DOD’s to VA’s health care system.
Collectively, a lack of leadership, oversight, resources, and
collaboration has contributed to the departments’ inability to fully
resolve problems facing recovering servicemembers and veterans.
Initially, departmental leadership exhibited focus and commitment—
through the Senior Oversight Committee—to addressing problems related
to case management and care coordination, disability evaluation
systems, and data sharing between DOD and VA. However, the committee’s
oversight waned over time, and in January 2012, it was merged with the
VA/DOD Joint Executive Council. Whether this council—which has
primarily focused on long-term strategic planning—can effectively
address the shorter-term policy focused issues once managed by the
Senior Oversight Committee remains to be seen. Furthermore, DOD does
not provide central oversight of the military services’ wounded
warrior programs, preventing it from determining how well these
programs are working across the department. However, despite these
shortcomings, the departments continue to take steps to resolve
identified problems, such as increasing the number of staff involved
with the electronic sharing of health records and the integrated
disability evaluation process. Additionally, while the departments’
previous attempts to collaborate on how to resolve case management and
care coordination problems have largely been unsuccessful, a joint
task force established in May 2012 is focused on resolving long-
standing areas of disagreement between VA, DOD, and the military
services. However, without more robust oversight and military service
compliance, consistent implementation of policies that result in more
effective case management and care coordination programs may be
unattainable.
What GAO Recommends:
GAO recommends that DOD provide central oversight of the military
services’ wounded warrior programs and that DOD and VA sustain high-
level leadership attention and collaboration to fully resolve
identified problems. DOD partially concurred with the recommendation
for central oversight of the wounded warrior programs, citing issues
with common eligibility criteria and systematic monitoring. DOD and VA
both concurred with the recommendation for sustained leadership
attention.
View [hyperlink, http://www.gao.gov/products/GAO-13-5]. For more
information, contact Randall B. Williamson at (202) 512-7114 or
williamsonr@gao.gov.
[End of section]
Contents:
Letter:
Background:
DOD and VA Have Not Fully Resolved Persistent Problems with Case
Management and Care Coordination, Disability Evaluation Systems, and
Electronic Sharing of Health Records:
DOD and VA Have Not Fully Resolved Long-standing Problems Due to
Deficiencies in Leadership and Oversight, Resources, and Collaboration:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Enrollment and Populations for Select Department of
Defense and Department of Veterans Affairs Programs:
Appendix II: Medical Category Assignment Process for Care Coordination
Programs:
Appendix III: Comments from the Department of Defense:
Appendix IV: Comments from the Department of Veterans Affairs:
Appendix V: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: Military Services' Wounded Warrior Programs: Types of
Services Provided:
Table 2: Eligibility Criteria for Military Services' Wounded Warrior
Programs:
Table 3: Military Services' Wounded Warrior Program Efforts to Measure
Program Performance:
Table 4: Military Services' Wounded Warrior Programs: Enrollment for
Fiscal Year 2011:
Table 5: Army Warrior Care and Transition Program Enrollment
Populations and Characteristics, Fiscal Years 2008 through 2011:
Table 6: Army Wounded Warrior Program Enrollment Populations and
Characteristics, Fiscal Years 2008 through 2011:
Table 7: Navy Safe Harbor Program Enrollment Populations and
Characteristics, Fiscal Years 2008 through 2011:
Table 8: Air Force Wounded Warrior Program Enrollment Populations and
Characteristics, Fiscal Years 2008 through 2011:
Table 9: Air Force Recovery Care Program Enrollment Populations and
Characteristics, Fiscal Years 2008 through 2011:
Table 10: Marine Corps Wounded Warrior Regiment Enrollment Populations
and Characteristics, Fiscal Years 2008 through 2011:
Table 11: United States Special Operations Command's Care Coalition
Enrollment Populations and Characteristics, Fiscal Years 2008 through
2011:
Table 12: Operation Enduring Freedom/Operation Iraqi Freedom/
Operation New Dawn (OEF/OIF/OND) Care Management Program Enrollment
Populations and Characteristics, Fiscal Years 2008 through 2011:
Table 13: Federal Recovery Coordination Program (FRCP) Enrollment
Populations and Characteristics, Fiscal Years 2008 through 2011:
Table 14: Referral Information Routinely Tracked by DOD and VA Case
Management and Care Coordination Programs:
Figures:
Figure 1: Timeline of Key Events in the 2-Year Period Following the
Walter Reed Army Medical Center Media Reports:
Figure 2: Original Senior Oversight Committee Organizational Chart,
including the Lines of Action (LOA) Workgroups:
Figure 3: The Department of Defense's Vision of the Assignment Process
for the Recovery Coordination Program and the Federal Recovery
Coordination Program:
Abbreviations:
DOD: Department of Defense:
Dole-Shalala Commission: President's Commission on Care for America's
Returning Wounded Warriors:
FRCP: Federal Recovery Coordination Program:
IDES: Integrated disability evaluation system:
LOA: Line of Action:
MTF: military treatment facility:
NDAA 2008: National Defense Authorization Act for Fiscal Year 2008:
OEF: Operation Enduring Freedom:
OIF: Operation Iraqi Freedom:
OND: Operation New Dawn:
PTSD: posttraumatic stress disorder:
RCP: Recovery Coordination Program:
Recovering Warrior Task Force: Department of Defense Task Force on the
Care, Management, and Transition of Recovering Wounded, Ill, and
Injured Members of the Armed Forces:
Senior Oversight Committee: Wounded, Ill, and Injured Senior Oversight
Committee:
TBI: traumatic brain injury:
VA: Department of Veterans Affairs:
VAMC: Department of Veterans Affairs Medical Center:
WWCTP: Office of Wounded Warrior Care and Transition Policy:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
November 16, 2012:
Congressional Committees:
A series of media reports in early 2007 disclosed troublesome
deficiencies in the provision of outpatient services at Walter Reed
Army Medical Center in Washington, D.C.[Footnote 1] These reports
prompted broader questions about whether the Departments of Defense
(DOD) and Veterans Affairs (VA) were fully prepared to meet the needs
of the growing number of servicemembers and veterans returning from
recent conflicts. Several review groups were subsequently tasked with
investigating the reported problems and identifying recommendations.
[Footnote 2] These groups identified common areas of concern
including: inadequate case management to ensure continuity of care,
[Footnote 3] confusing disability evaluation systems, and insufficient
sharing of servicemembers' health records and other data between DOD
and VA--all long-standing problems that we have reported on
extensively.[Footnote 4]
To elevate the response to concerns raised by these review groups, DOD
and VA established the Wounded, Ill, and Injured Senior Oversight
Committee (Senior Oversight Committee) in May 2007. The committee was
intended to operate on a short-term basis to review and implement the
recommendations made by the various review groups and improve
seamlessness in the provision of care for recovering servicemembers
and veterans.[Footnote 5] It was cochaired by the Deputy Secretaries
of Defense and Veterans Affairs and included the military service
Secretaries and other high-ranking officials within the departments.
Congress subsequently passed the National Defense Authorization Act
for Fiscal Year 2008 (NDAA 2008) requiring the Secretary of Defense
and the Secretary of Veterans Affairs to jointly develop and implement
policy, to the extent feasible, to improve the care, management, and
transition of recovering servicemembers.[Footnote 6] Because of its
related ongoing work, the Senior Oversight Committee also assumed
responsibility for addressing these requirements.
Despite actions taken by DOD and VA to address the problems identified
at Walter Reed in 2007, concerns remain that recovering servicemembers
and veterans continue to face many of the same problems as they did in
2007 navigating the recovery care continuum, from acute medical
treatment and stabilization, through rehabilitation, to reintegration-
-either back to active duty or to the civilian community as a veteran.
In 2009, Congress required DOD to establish a task force to assess the
effectiveness of DOD programs and policies developed to assist
recovering servicemembers and to make recommendations for continuous
improvements of such policies and programs.[Footnote 7] The DOD Task
Force on the Care, Management, and Transition of Recovering Wounded,
Ill, and Injured Members of the Armed Forces--referred to as the
Recovering Warrior Task Force--issued its first report in September
2011;[Footnote 8] it contained 21 recommendations on a variety of
issues affecting recovering servicemembers.[Footnote 9] Additionally,
congressional committees held multiple hearings in 2010 and 2011 that
highlighted ongoing difficulties facing these servicemembers and
veterans, including issues with duplication and poor coordination
among case management and care coordination programs,[Footnote 10]
delays in completing the disability evaluation process, and the lack
of full interoperability between DOD's and VA's computer systems.
[Footnote 11]
The NDAA 2008 required that we report on DOD's and VA's progress in
developing and implementing joint policy on issues related to the
care, management, and transition of recovering
servicemembers.[Footnote 12] As discussed with the committees of
jurisdiction, we have reviewed and reported on the departments'
progress with respect to various topic areas. This review, which is
focused on the continuity of care for recovering servicemembers and
veterans, is the latest in our body of work.[Footnote 13] In this
review, we are reporting on:
1. the extent to which DOD and VA have resolved persistent problems
facing recovering servicemembers and veterans as they navigate the
recovery care continuum and:
2. the reasons DOD and VA leadership have not been able to fully
resolve any remaining problems.
To respond to these objectives, we interviewed the directors of the
following case management and care coordination programs,[Footnote 14]
including:
* the Army Warrior Care and Transition Command's Warrior Transition
Units and the Army Wounded Warrior Program,
* the Navy Safe Harbor Program,
* the Air Force Recovery Care Program and the Air Force Wounded
Warrior Program,
* the Marine Corps Wounded Warrior Regiment,
* the United States Special Operations Command's Care Coalition,
* the Federal Recovery Coordination Program, and:
* VA's Operation Enduring Freedom/Operation Iraqi Freedom/Operation
New Dawn (OEF/OIF/OND) Care Management Program.
We collected data for each of these programs, such as the number of
enrollees over time. (See appendix I for data on enrollment and
population characteristics for these programs.) We also reviewed
documents describing the scope, mission, and leadership of these
selected programs.
In addition, we took the following steps to determine the extent to
which DOD and VA have resolved persistent problems affecting
recovering servicemembers and veterans along the recovery care
continuum:
* We visited a judgmental sample of 11 DOD military treatment
facilities (MTF) and VA Medical Centers (VAMC) to identify variations
in how care coordination and case management programs are being
operated at the local level. We focused on Army and Marine Corps MTFs
because, collectively, the wounded warrior programs for these military
services serve more than 70 percent of the wounded, ill, and injured
servicemember and veteran population. We selected facilities that
provide or have access to significant medical and rehabilitation
resources as well as facilities that have fewer medical or
rehabilitation resources. The sites we visited included MTFs at Fort
Bragg (N.C.), Fort Knox (Ky.), Fort Carson (Colo.), Fort Belvoir
(Va.), Fort Meade (Md.), Walter Reed National Military Medical Center
(Md.), Camp Lejeune (N.C.), and Quantico (Va.), and VAMCs in Richmond,
Virginia; Denver, Colorado; and the District of Columbia. At these
facilities, we met with local leadership officials and the officials
responsible for managing the facilities' case management and care
coordination programs, and we obtained information on how these
programs were working as well as the types of problems that recovering
servicemembers and veterans continue to face. While at these
facilities, we met with recovering servicemembers and veterans to
obtain information about their experiences.
* We interviewed officials from military and veteran advocacy groups
to obtain their members' perspective on any problems that persist in
navigating the recovery care continuum.
* We interviewed the director of the VA Liaison for Healthcare Program
to understand VA's role in assisting recovering servicemembers'
transition from DOD's to VA's health care system.
* We met with members of the Recovering Warrior Task Force, reviewed
relevant task force documentation, and attended its public meetings to
obtain information about problems they identified that affect
recovering servicemembers and veterans.
* We reviewed published and ongoing studies and GAO reports[Footnote
15] describing problems that recovering servicemembers and veterans
face, including issues related to the disability evaluation system and
the electronic sharing of health records between DOD and VA.
To identify the reasons why DOD and VA leadership have not fully
resolved any remaining problems facing recovering servicemembers and
veterans, we reviewed relevant documentation to identify the roles of
DOD and VA offices that coordinate or oversee case management or care
coordination programs, their placement within their respective
departments, and whether and how these offices monitor the performance
of the programs we reviewed. We also obtained information about
organizational and program changes, including officials' views about
the potential impact of these changes. We also interviewed key DOD and
VA leadership officials, such as the Deputy Assistant Secretary of
Defense for Wounded Warrior Care and Transition Policy, VA's Chief of
Staff, and former and current officials from the departments'
coordinating and oversight offices, including the Senior Oversight
Committee, DOD's Office of Wounded Warrior Care and Transition Policy,
the Interagency Program Office, and the VA/DOD Collaboration Service,
which is an office within VA. To obtain information about recent
efforts DOD and VA have initiated to address problems facing
servicemembers and veterans, we interviewed DOD and VA officials
participating in these activities, including officials involved in the
DOD and VA Warrior Care and Coordination Taskforce. We also reviewed
the documentation available regarding the departments' recent efforts;
however, we predominately relied on testimonial evidence provided by
these officials.
The NDAA 2008 also requires us to certify whether we had timely access
to sufficient information to make informed judgments on the matters
covered by our report. We were provided sufficient information in a
timely manner to assess the extent to which DOD and VA have resolved
persistent problems facing recovering servicemembers and veterans as
they navigate the recovery care continuum and the reasons DOD and VA
leadership have not been able to fully resolve any remaining problems.
We conducted this performance audit from July 2011 through September
2012 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit
to obtain sufficient, appropriate evidence to provide a reasonable
basis for our findings and conclusions based on our audit objectives.
We believe that the evidence obtained provides a reasonable basis for
our findings and conclusions based on our audit objectives.
Background:
Review groups identified significant problems after the media reports
concerning Walter Reed. Initial efforts to respond to these problems
were primarily coordinated through the Senior Oversight Committee, and
DOD and VA undertook additional efforts to respond to these problems.
Review Groups Identified Problems across the Recovery Care Continuum:
Following the revelations at Walter Reed, several review groups noted
significant problems that may arise during servicemembers' recovery
from wounds, illnesses, and injuries.[Footnote 16] Some of these
problems involve the provision of appropriate medical care, while
others involve the acquisition of needed DOD and VA benefits. In 2007,
one of the review groups, the President's Commission on Care for
America's Returning Wounded Warriors--commonly referred to as the Dole-
Shalala Commission--noted that recovering servicemembers depend on the
effective and efficient provision of medical services and benefits
across the recovery care continuum,[Footnote 17] which is separated
into three phases:
* recovery, when wounded, ill, and injured servicemembers are
stabilized and receive acute inpatient medical treatment at an MTF,
VAMC, or private medical facility;
* rehabilitation, when recovering servicemembers with complex trauma,
such as missing limbs, receive medical and rehabilitative care; and:
* reintegration, when servicemembers either return to active duty or
to the civilian community as veterans.
A recovering servicemember or veteran may not experience the recovery
care continuum as a linear process, and may move back and forth across
the continuum over time, depending on his or her medical needs. For
example, a servicemember who has transitioned to the rehabilitation
phase may go back to the recovery phase if there is a need to return
to an MTF to obtain acute medical care, such as a surgical procedure.
Initial Efforts to Address Problems Were Coordinated by the Senior
Oversight Committee:
DOD and VA took a number of steps to address the problems identified
by the review groups that investigated the issues raised by the Walter
Reed media reports. As an initial step, the departments established
the Senior Oversight Committee to coordinate and oversee DOD's and
VA's efforts to jointly resolve these problems. Through this
committee, DOD and VA created programs and initiatives to assist
recovering servicemembers and veterans as they navigate the recovery
care continuum. Key efforts included the establishment of the
integrated disability evaluation system (IDES), the Federal Recovery
Coordination Program (FRCP), the Recovery Coordination Program (RCP),
and the Interagency Program Office. (See figure 1.)
Figure 1: Timeline of Key Events in the 2-Year Period Following the
Walter Reed Army Medical Center Media Reports:
[Refer to PDF for image: timeline]
February 2007:
Walter Reed story breaks.
April 2007:
Review groups began releasing reports[A].
May 2007:
Senior Oversight Committee established.
July 2007:
Dole-Shalala report released.
November 2007:
Integrated Disability Evaluation System Pilot initiated.
January 2008:
Federal Recovery Coordination Program initiated.
November 2008:
Recovery Coordination Program initiated.
January 2009:
Interagency Program Office established.
Source: Department of Defense.
[A] Several review groups, including the Dole-Shalala Commission, were
tasked with investigating the problems reported at Walter Reed Army
Medical Center in Washington, D.C., and identifying recommendations.
The other review groups included the Independent Review Group,
Rebuilding the Trust: Report on Rehabilitative Care and Administrative
Processes at Walter Reed Army Medical Center and National Naval
Medical Center (Arlington, Va.: April 2007); Task Force on Returning
Global War on Terror Heroes, Report to the President (April 2007);
Veterans' Disability Benefits Commission, Honoring the Call to Duty:
Veterans' Disability Benefits in the 21st Century (October 2007); and
Department of Defense Office of the Inspector General, Department of
Veterans Affairs Office of the Inspector General, DOD/VA Care
Transition Process for Service Members Injured in OIF/OEF (June 2008).
[End of figure]
Senior Oversight Committee. The Senior Oversight Committee was
responsible for ensuring that the recommendations--which totaled more
than 600 from the various review groups--were properly reviewed,
coordinated, implemented, and resourced. Supporting the Senior
Oversight Committee was an Overarching Integrated Product Team, the
membership of which included the Assistant Secretaries of Defense, the
military departments' Assistant Secretaries for Manpower and Reserve
Affairs, and various senior officials from DOD and VA. This team
coordinated, integrated, and synchronized the work of the eight "Lines
of Action" (LOA) that focused on specific issues, including case
management, disability evaluation systems, and data sharing between
DOD and VA. (See figure 2.)
Figure 2: Original Senior Oversight Committee Organizational Chart,
including the Lines of Action (LOA) Workgroups:
[Refer to PDF for image: organizational chart]
Top level: Senior Oversight Committee.
Second level: Reporting to Senior Oversight Committee:
Overarching Integrated Program Team.
Third level: Reporting to Overarching Integrated Program Team:
LOA 1 Disability System;
LOA 2 Traumatic Brain Injury/Post Traumatic Stress Disorder;
LOA 3 Case Management;
LOA 4 DOD/VA Data Sharing;
LOA 5 Facilities;
LOA 6 Clean Sheet Design;
LOA 7 Legislation and Public Affairs;
LOA 8 Personnel, Pay and Financial Support.
Source: Senior Oversight Committee.
[End of figure]
Each LOA included representation from DOD, including each military
service, and VA. They performed the bulk of the work to address the
issues and recommendations of the various review groups, including
establishing plans, setting and tracking milestones, and identifying
and enacting early and short-term solutions. More specifically, the
LOAs were as follows:
* LOA 1--Disability Evaluation: Responsible for addressing efforts to
reform the DOD and VA disability evaluation systems.
* LOA 2--Traumatic Brain Injury (TBI)/Post Traumatic Stress Disorder
(PTSD): Responsible for addressing issues related to TBI/PTSD.
* LOA 3--Case Management: Responsible for addressing issues related to
the care, management, and transition of recovering servicemembers from
recovery to rehabilitation and reintegration.
* LOA 4--DOD/VA Data Sharing: Responsible for addressing issues
regarding the electronic exchange of DOD and VA health records.
* LOA 5--Facilities: Responsible for addressing issues relating to
military and VA medical facilities.
* LOA 6--"Clean Sheet" Review: Developed recommendations to improve
care and benefits without the constraints of existing laws,
regulations, organizational roles, personnel constraints, or budgets.
* LOA 7--Legislation and Public Affairs: Responsible for addressing
legal and other issues for policy development.
* LOA 8--Personnel, Pay, and Financial Support: Responsible for
addressing compensation and benefit issues.
Some of the key efforts initiated out of the LOAs included the
establishment of an integrated disability evaluation system, care
coordination programs, and steps towards the electronic exchange of
DOD and VA health records--a responsibility that was later assumed by
the Interagency Program Office.
DOD/VA Integrated Disability Evaluation System. Through LOA 1, DOD and
VA jointly began to develop and pilot IDES to improve the disability
evaluation process by eliminating duplication in DOD's and VA's
separate evaluation systems and expediting the receipt of VA benefits.
Specifically, IDES merges DOD's and VA's separate medical exams for
servicemembers into a single exam process; consolidates DOD's and VA's
separate disability rating decisions into a single VA rating decision;
and provides staff to perform outreach and nonclinical case management
and explain VA results and processes to servicemembers. By October
2011, DOD and VA had fully deployed IDES at 139 MTFs in the United
States and several other countries.
Care Coordination Programs. LOA 3 took the lead role in addressing
problems with uncoordinated case management for recovering
servicemembers and veterans through the establishment of two care
coordination programs--the FRCP and the RCP. The FRCP was based on a
recommendation from the Dole-Shalala Commission that a single
individual--a recovery coordinator--would work with existing DOD and
VA case managers to ensure that servicemembers had the resources
needed for their care. LOA 3 designed the FRCP to assist "severely"
wounded, ill, and injured OEF and OIF[Footnote 18] servicemembers,
veterans, and their families with access to care, services, and
benefits. This population includes servicemembers and veterans who
suffer from traumatic brain injuries, amputations, burns, spinal cord
injuries, visual impairment, and PTSD. The program uses federal
recovery coordinators to monitor and coordinate clinical services,
including facilitating and coordinating medical appointments, and
nonclinical services, such as providing assistance with obtaining
financial benefits or special accommodations, needed by program
enrollees and their families. Federal recovery coordinators, who are
senior-level registered nurses and licensed clinical social workers,
were intended to serve as the single point of contact among all of the
case managers of DOD, VA, and other governmental and nongovernmental
programs[Footnote 19] that provide services directly to servicemembers
and veterans. Although the FRCP was designed as a joint program, it is
administered by VA, and the federal recovery coordinators are VA
employees.
LOA 3 subsequently developed the RCP in response to a requirement in
the NDAA 2008. The RCP is a DOD-specific program that uses recovery
care coordinators to coordinate nonclinical services and resources for
"seriously" wounded, ill, and injured servicemembers who may return to
active duty, unlike those categorized as "severely" wounded, ill, and
injured, who are not likely to return to duty and would be served by
the FRCP. The military services were responsible for separately
implementing the RCP through each of their existing wounded warrior
programs as a means of providing care coordination services to program
enrollees.
Electronic Sharing of Health Records. LOA 4 was focused on addressing
issues related to the electronic exchange of DOD and VA health
records. However, this effort was superseded by the NDAA 2008,
[Footnote 20] which required the establishment of the Interagency
Program Office to serve as a single point of accountability for both
departments in the development and implementation of interoperable
electronic health records.[Footnote 21] Although DOD and VA retained
the responsibility for the development and management of the
information technology systems, the Interagency Program Office was
responsible for ensuring the implementation of an electronic health
records system or capabilities that allowed for the complete sharing
of health care information for the provision of clinical care. In
October 2011, the Interagency Program Office also became accountable
for DOD's and VA's work on developing an integrated electronic health
records system that both departments would use for their beneficiaries.
Additional Efforts by DOD and VA to Address Problems Facing Recovering
Servicemembers and Veterans:
In addition to the Senior Oversight Committee's efforts, DOD, its
military services, and VA developed or modified a number of programs
and initiatives to assist recovering servicemembers and veterans in
navigating the recovery care continuum.
Military Services' Wounded Warrior Programs. The military services'
wounded warrior programs were established to assist recovering
servicemembers[Footnote 22] during their recovery, rehabilitation, and
initial reintegration back to active duty or to civilian life. Most of
these programs provide nonclinical case management services to the
recovering servicemembers; that is, they help to resolve issues
related to finances, benefits and compensation, administrative and
personnel paperwork, housing, and transportation. In addition, the
wounded warrior programs serve as the central point of access to other
types of services or resources that support recovering servicemembers,
such as clinical case management, care coordination, and career,
education, and readiness services. (See table 1.) If a wounded warrior
program does not directly provide a service or resource, it can
facilitate servicemembers' access to that service or resource.
Although the wounded warrior programs were intended mainly to provide
services to recovering servicemembers, all but one of the programs
continue to assist individuals after they have transitioned to veteran
status.
Table 1: Military Services' Wounded Warrior Programs: Types of
Services Provided:
Army:
Military services' wounded warrior program: Army Warrior Care and
Transition Program: Warrior Transition Units and Community-Based
Warrior Transition Units[B];
Types of services provided:
Clinical case management: [Check];
Nonclinical case management: [Check];
Care coordination: [Empty];
Career, education, and readiness[A]: [Check].
Military services' wounded warrior program: Army Warrior Care and
Transition Program: Army Wounded Warrior Program;
Types of services provided:
Clinical case management: [Empty];
Nonclinical case management: [Empty];
Care coordination: [Check];
Career, education, and readiness[A]: [Check].
Navy/Coast Guard:
Military services' wounded warrior program: Navy Safe Harbor Program;
Types of services provided:
Clinical case management: [Empty];
Nonclinical case management: [Empty];
Care coordination: [Check];
Career, education, and readiness[A]: [Check].
Air Force:
Military services' wounded warrior program: Air Force Wounded Warrior
Program;
Types of services provided:
Clinical case management: [Empty];
Nonclinical case management: [Check];
Care coordination: [Empty];
Career, education, and readiness[A]: [Check].
Military services' wounded warrior program: Air Force Recovery Care
Program;
Types of services provided:
Clinical case management: [Empty];
Nonclinical case management: [Empty];
Care coordination: [Check];
Career, education, and readiness[A]: [Check].
Marines Corps:
Military services' wounded warrior program: Marine Wounded Warrior
Regiment;
Types of services provided:
Clinical case management: [Empty];
Nonclinical case management: [Check];
Care coordination: [Check];
Career, education, and readiness[A]: [Check].
United States Special Operations Command:
Military services' wounded warrior program: United States Special
Operations Command's Care Coalition;
Types of services provided:
Clinical case management: [Empty];
Nonclinical case management: [Check];
Care coordination: [Check];
Career, education, and readiness[A]: [Check].
Source: GAO analysis of military services' wounded warrior program
information.
Notes: The characteristics listed in this table are general
characteristics of each program; individual circumstances may affect
the services provided by specific programs. For the purposes of this
report, clinical case management services include services such as
scheduling medical appointments and providing outreach education about
medical conditions such as PTSD. Nonclinical case management services
include services such as assisting servicemembers with financial
benefits and accessing accommodations for families.
[A] Career, education, and readiness services are provided through
programs such as the Warrior Athlete Reconditioning Program and DOD's
Operation Warfighter Program and Education and Employment Initiative.
The Warrior Athlete Reconditioning Program enhances recovery by
engaging wounded, ill, and injured servicemembers in individualized
physical and cognitive activities outside of traditional therapy
settings. Operation Warfighter is a federal internship program for
wounded, ill, and injured servicemembers that places them in
supportive work settings to prepare them to return to active duty or
to transition into jobs in the government or private sector. To access
the Operation Warfighter Program a recovering servicemember has to be
enrolled in a military service wounded warrior program. In addition,
the military services' wounded warrior programs facilitate access to
other programs such as the Warrior Athlete Reconditioning Program.
[B] A warrior transition unit is technically an Army brigade,
battalion, or company that provides command and control,
administrative support, primary care and case management and other
services to support soldiers and their families during recovery,
rehabilitation, and transition back to active duty or to civilian
life. For the purposes of this report, we are categorizing it as a
wounded warrior program.
[End of table]
VA Transition Programs. VA's Liaison for Healthcare Program and its
OEF/OIF/OND Care Management Program assist recovering servicemembers
with transitioning from DOD's to VA's health care system. As of August
2012, the Liaison for Healthcare Program employed 33 liaisons at 18
MTFs nationwide.[Footnote 23] After a DOD or VA treatment team
determines that a recovering servicemember is medically ready to
transition to a VAMC, a VA liaison facilitates the transfer from an
MTF to a VAMC closest to their homes or to the most appropriate
locations for the specialized services their medical condition
requires. VA liaisons follow recovering servicemembers as they enter
the VA health care system, ensuring that their first VA appointments
are scheduled. Thereafter, the VA OEF/OIF/OND Care Management Program
team assigned to each recovering individual coordinates the
individual's care at the VAMC and provides ongoing follow-up.[Footnote
24] Each VAMC has an OEF/OIF/OND Care Management Program team in place
to coordinate patient care activities.
DOD and VA Have Not Fully Resolved Persistent Problems with Case
Management and Care Coordination, Disability Evaluation Systems, and
Electronic Sharing of Health Records:
Recovering Servicemembers and Veterans Do Not Always Have Access to
the Case Management and Care Coordination Programs Designed to Assist
Them:
Recovering servicemembers' access to case management and care
coordination programs has been impeded by two main factors--(1) the
limited ability to identify and refer those servicemembers who could
benefit from enrollment in the programs along with officials'
reluctance to refer them, and (2) variations in eligibility criteria
among the military services' wounded warrior programs, resulting in
access disparities for similarly situated recovering servicemembers.
[Footnote 25]
Recovering Servicemembers Are Not Always Identified and Referred to
Programs That May Benefit Them:
We found that referrals may be lacking or delayed (1) from military
service unit commanders to wounded warrior programs; (2) from wounded
warrior programs to the FRCP; and (3) for certain groups of
servicemembers, such as those with "invisible injuries" as well as
members of the National Guard and Reserve.
Referral to the military services' wounded warrior programs. The
military services' wounded warrior programs primarily use referrals to
identify recovering servicemembers that might be eligible for
enrollment. However, we found that the methods for referral, which
include casualty reports and direct referrals, are imprecise, such
that all servicemembers who could benefit from being enrolled in these
programs are not necessarily identified and referred.
Officials from three wounded warrior programs told us that casualty
reports are the primary method for receiving referrals.[Footnote 26]
Casualty reports are initial alerts to military personnel, including
wounded warrior program officials, that a servicemember has been
injured. These reports can be initiated by unit commands or other
military personnel as a method of referral to the wounded warrior
programs. However, wounded warrior program officials from four wounded
warrior programs told us that casualty reports are not created after
every injury or may be created late in a servicemember's recovery. In
particular, some of these officials said that military service unit
command staff may delay or not create casualty reports for
servicemembers not injured in combat, such as for injuries that occur
stateside or while on leave, because servicemembers' units may not
find out about such incidents immediately.
According to wounded warrior program officials, referrals to wounded
warrior programs also can be made directly from unit command staff and
other sources, including staff at the MTF where a recovering
servicemember is receiving treatment or through self-referrals.
[Footnote 27] These referrals also may not be made in a timely manner.
Specifically, unit command staff may not refer potentially eligible
servicemembers to wounded warrior programs because either they want to
"take care of their own" or because they are not well informed about
the programs and the services they provide, according to wounded
warrior program officials. For example, a wounded warrior program
official told us that he identified a servicemember who had sustained
a gunshot wound to the head but was still assigned to his combat unit.
This official explained that even though the servicemember was
receiving treatment, he could have benefited from being enrolled in
the wounded warrior program because of the additional assistance it
provides, including nonclinical case management and care coordination
services. Additionally, several recovering servicemembers told us that
they encountered difficulties in their recovery as a result of staying
in their units and not being referred to a wounded warrior program
earlier. For example, a recovering servicemember told us that despite
having been recently discharged from a hospital for arm injuries, he
was required to operate a floor buffing machine in his unit, which was
difficult for him as a result of his injuries. He did not receive
rehabilitative treatment for his injuries until he was assigned to a
wounded warrior program. Furthermore, we found that most of the
military services' wounded warrior programs do not always track the
number of referrals to their programs, including data on whether or
not servicemembers referred to the programs were actually enrolled.
(See table 14 in appendix I for additional information about referral
data.) Without this information, it is not clear whether all those who
could benefit from a wounded warrior program are being enrolled.
Referral to the FRCP. In addition to problems with referrals to
wounded warrior programs, wounded warrior program officials sometimes
delay or fail to make referrals of potentially eligible servicemembers
to the FRCP, which coordinates care across the departments and
throughout the recovery care continuum. As we have previously
reported, the FRCP relies predominantly on referrals from other
sources, including wounded warrior program officials and clinical
treatment teams, because it does not have a systematic way to identify
potential enrollees.[Footnote 28] Referrals to the FRCP are important
because federal recovery coordinators are intended to provide
continuity of care throughout servicemembers' recovery, starting with
their initial treatment at an MTF and throughout the recovery care
continuum. They can also assist in facilitating recovering
servicemembers' access to VA services and benefits while
servicemembers are still on active duty, according to VA officials.
[Footnote 29] However, we found that officials from wounded warrior
programs view the jointly created and established FRCP as a VA program
and, therefore, delay their referrals until it is certain that the
servicemember will become a veteran.
Referrals for certain servicemember populations. We found that certain
servicemember populations may be at greater risk for not being
identified for DOD and VA case management and care coordination
programs. Specifically, according to wounded warrior program
officials, servicemembers who have undiagnosed, "invisible" wounds,
such as PTSD and TBI, may be at greater risk of not being referred to
a wounded warrior program or the FRCP until it becomes apparent that
the servicemember cannot be deployed. For example, a servicemember
told us that although he was experiencing anxiety every time he put on
his uniform, it was not until he had a severe anxiety attack, as a
result of his PTSD, that he was hospitalized and then referred to a
wounded warrior program. According to officials representing military
advocacy organizations, National Guard and Reserve servicemembers may
be particularly reluctant to identify injuries and illnesses because
they are eager to return home and do not want to be delayed at the
installation for an evaluation of any conditions they may have.
However, these officials said that when these servicemembers have been
deactivated and problems manifest themselves later on, they may
experience difficulties establishing that their injuries or illnesses
are a result of their service in the military, which could make it
difficult for them to access services and programs provided by DOD and
VA.
Recovering Servicemembers' Access to the Military Services' Wounded
Warrior Programs Is Likely to Be Inequitable Due to Variations in
Their Eligibility Criteria:
Because of variations in eligibility criteria among the military
services' wounded warrior programs, DOD cannot assure that similarly
situated servicemembers have equitable access to these programs,
leading to disparities in the level of assistance provided across the
military services. (See table 2.) For example, servicemembers can only
be eligible for the Air Force Wounded Warrior Program if they have a
combat-related injury or illness, whereas servicemembers with combat
or non-combat-related injuries or illnesses can be eligible for the
Army's Warrior Transition Units.
Table 2: Eligibility Criteria for Military Services' Wounded Warrior
Programs:
Army:
Military services' wounded warrior program: Army Warrior Care and
Transition Program: Warrior Transition Units and Community-Based
Warrior Transition Units;
Eligibility criteria: Serves servicemembers who require at least 6
months of rehabilitative care and complex medical management[A].
Military services' wounded warrior program: Army Warrior Care and
Transition Program: Army Wounded Warrior Program;
Eligibility criteria: Serves "severely" wounded, ill, and injured
servicemembers in the warrior transition units who have, or are
expected to receive, a physical evaluation disability rating[B] of 30
percent or greater in one or more specific categories or a combined
rating of 50 percent or greater for conditions that are combat-related.
Navy/Coast Guard:
Military services' wounded warrior program: Navy Safe Harbor Program;
Eligibility criteria: Serves "seriously" wounded, ill, and injured
sailors and coast guardsmen not likely to return to duty in 180 days
and likely to be medically retired, as well as high-risk wounded, ill,
and injured sailors that have less serious health concerns.
Air Force:
Military services' wounded warrior program: Air Force Wounded Warrior
Program;
Eligibility criteria: Serves servicemembers with a combat-related
injury or illness that requires long-term care[C] as well as
examinations to determine fitness for duty.
Military services' wounded warrior program: Air Force Recovery Care
Program;
Eligibility criteria: Serves all servicemembers who are "seriously"[D]
ill and injured either in a combat-related incident or in a non-combat-
related incident.
Marines Corps:
Military services' wounded warrior program: Marine Wounded Warrior
Regiment;
Eligibility criteria: Serves servicemembers who require more
than 90 days of medical treatment or rehabilitation. A recovering
servicemember also may be assigned to the Wounded Warrior Regiment
when:
* the unit command cannot support transportation requirements to
the military treatment facility;
* the Marine cannot serve a function in the unit command due to
his/her injuries or illness, or;
* the Marine has three or more medical appointments per week.
United States Special Operations Command:
Military services' wounded warrior program: United States Special
Operations Command's Care Coalition;
Eligibility criteria: Assists Special Forces servicemembers who are;
* wounded, injured, or ill evacuated from a combat area;
* wounded, injured, or ill returned to duty or redeployed; or;
* injured or ill whose injury or illness is not combat-related.
Source: GAO analysis of military services' wounded warrior program
information.
[A] Reservists in need of definitive medical treatment for conditions
caused or aggravated while on active duty or training status are also
eligible.
[B] After medical examinations are conducted to determine a
servicemember's ability to continue to serve in the military, decisions
are made about the servicemember's fitness for duty and about a
servicemember's disability rating, which determines the DOD and VA
benefits he or she can receive.
[C] According to an Air Force Wounded Warrior Program official, the
program does not define long-term care or provide criteria related to
the time needed for recovery.
[D] According to an Air Force Recovery Care Program official, a
servicemember is designated as "seriously' ill or injured on the basis
of a medical diagnosis made by Air Force medical staff when referred to
the program; the program does not make this designation.
Source: GAO analysis of military services' wounded warrior program
information.
[A] Reservists in need of definitive medical treatment for conditions
caused or aggravated while on active duty or training status are also
eligible.
[B] After medical examinations are conducted to determine a
servicemember's ability to continue to serve in the military,
decisions are made about the servicemember's fitness for duty and
about a servicemember's disability rating, which determines the DOD
and VA benefits he or she can receive.
[C] According to an Air Force Wounded Warrior Program official, the
program does not define long-term care or provide criteria related to
the time needed for recovery.
[D] According to an Air Force Recovery Care Program official, a
servicemember is designated as "seriously' ill or injured on the basis
of a medical diagnosis made by Air Force medical staff when referred
to the program; the program does not make this designation.
[End of table]
As a result of these differences in eligibility criteria, recovering
servicemembers in one military service may qualify for entry in their
wounded warrior program while similarly situated servicemembers in
another military service do not have access to their program.
Consequently, according to wounded warrior program officials, some
recovering servicemembers do not have access to services that would
otherwise be available to them, including the RCP and Operation
Warfighter.[Footnote 30] Additionally, because wounded warrior
programs facilitate access to other programs and services, including
the VA Liaison for Healthcare Program and the Warrior Athlete
Reconditioning Program,[Footnote 31] not being eligible for a
particular wounded warrior program could preclude a servicemember from
receiving the services of these other programs.[Footnote 32] Military
coalition officials who advocate for recovering servicemembers and
their families told us the lack of standardization across similar
programs, such as the military services' wounded warrior programs, is
one of the main reasons recovering servicemembers "fall through the
cracks" or do not get the services that they need when they are
navigating the recovery care continuum.
DOD is aware of inconsistencies in eligibility criteria among the
military services' wounded warrior programs and the potential for
disparities in the provision of services and assistance that may
result. DOD has not taken action to correct this, however, despite the
identification of this issue as a potential problem for recovering
servicemembers by a congressionally mandated DOD task force.
Specifically, in its 2011 annual report to congressional committees,
the Recovering Warrior Task Force noted that as a result of
differences in eligibility criteria among the military services,
certain subpopulations of recovering servicemembers may be at a
disadvantage.[Footnote 33] In response to this report, DOD stated that
although there are no DOD-wide criteria for entry into wounded warrior
programs, the individual military services already have policies in
place as a result of the flexibility given to them by DOD.
Delays in DOD's and VA's Integrated Disability Evaluation System
Persist, Limiting Recovering Servicemembers' Ability to Plan for Their
Future:
Although IDES provides improved timeliness over the separate DOD and
VA disability evaluation systems, processing times have continued to
increase since its implementation in November 2007, resulting in
frustration and uncertainty for servicemembers going through the
process. In a May 2012 hearing,[Footnote 34] we testified that the
average number of days for servicemembers to complete the IDES process
and receive VA benefits increased from 283 in fiscal year 2008 to 394
in fiscal year 2011 for active duty cases (compared to the goal of 295
days) and from 297 to 420 for reserve cases, respectively (compared to
the goal of 305 days).[Footnote 35]
While there are many reasons for increases in processing times,
[Footnote 36] recovering servicemembers and wounded warrior program
officials told us that extended timelines in the IDES process and the
lack of a firm completion date limits recovering servicemembers'
ability to plan for their future. Several recovering servicemembers
said that not being given a timeframe for completion of the IDES
process is frustrating, particularly when their own providers are
unable to obtain additional information on the status of their case.
For example, a servicemember told us that after going through the IDES
process, receiving a rating, and filing an appeal over a year ago, he
still did not know the status of his case, negatively affecting his
ability to plan for his future. Similarly, a wounded warrior program
official also told us that her program has had several servicemembers
lose job opportunities because they applied for positions thinking
that they would be through the IDES process by a certain date, but
when that date was pushed back, the employers rescinded their offers.
Wounded warrior program officials from some of the sites we visited
told us that extended waiting periods resulting from the disability
process also may lead to some recovering servicemembers engaging in
negative behavior, including drug use. Wounded warrior program
officials told us that after waiting for so long in the wounded
warrior barracks due to the lengthy disability process, servicemembers
can get depressed, resist or just stop going to medical appointments,
and stop working on their recovery. Similarly, the DOD Inspector
General has reported that lengthy IDES processing times has
contributed to a negative and even counterproductive environment,
which was not conducive to servicemembers' recovery and
transition.[Footnote 37] To prevent these problems, we found that two
wounded warrior programs require recovering servicemembers to
participate in programs such as the Warrior Athlete Reconditioning
Program and Operation Warfighter. A recovering servicemember told us
that soon after being assigned to the wounded warrior program, he was
referred to the Warrior Athlete Reconditioning Program, which gave him
something to do other than "sitting around." Another recovering
servicemember told us that the Warrior Athlete Reconditioning Program
is an effective motivator for recovery.
Conversely, the servicemembers could take actions that may impact
their own processing times in IDES and, therefore, their length of
stay in a wounded warrior program. We found that some servicemembers
may appeal their disability decisions to prolong their own recovery
and transition out of the military. According to wounded warrior
program officials from some of the sites we visited, some
servicemembers resist their transfer out of the wounded warrior
program and the military because they want to continue to take
advantage of the opportunities and services available to them,
including the financial security of a regular paycheck. For example, a
wounded warrior program official and a VA official told us that some
servicemembers will purposefully miss appointments to delay the IDES
process because they feel that they are not ready to leave the program.
DOD and VA Have Yet to Develop Sufficient Capability to Electronically
Share Health Records, Potentially Delaying Servicemembers' Receipt of
Coordinated Care and Benefits:
The departments have not yet developed sufficient capability to
electronically share servicemembers' and veterans' complete health
records, which can delay the receipt of care and benefits for
recovering servicemembers and veterans. As we have previously
reported, for over a decade DOD and VA have undertaken several efforts
to improve the ability of their information technology systems to
electronically share health records.[Footnote 38] For example, the
Federal Health Information Exchange, which was started in 2001 and
completed in 2004, allows DOD to electronically transfer
servicemembers' health information to VA when they leave active duty.
In addition, the departments' Bidirectional Health Information
Exchange was established in 2004 to allow clinicians in both
departments to view limited health information on patients who receive
care from both departments. More recently, the departments have
undertaken two new joint initiatives, the Virtual Lifetime Electronic
Record and an integrated electronic health records system, in an
effort to increase electronic health record interoperability and
modernize their systems.
We found that although DOD and VA care providers were expected to have
access to some electronic health record information across the
departments, the DOD and VA care providers that we spoke to still did
not have the ability to electronically share complete health records
for recovering servicemembers who were transferring between DOD's and
VA's health care systems, and therefore they had to use other methods.
For example, wounded warrior program and VA officials told us that
they had to resort to copying and faxing recovering servicemembers'
health records to VAMC staff in preparation for a servicemember's
transition from DOD's to VA's health care system because there was not
an automatic, electronic way to transfer them. In addition to copying
and faxing health records, according to VA officials we spoke with,
DOD and VA staff may hold a video-teleconference between the
transferring MTF and receiving VA health care facilities to exchange
information.
In addition, wounded warrior program and VA officials who help
servicemembers transition from DOD to VA told us that they only share
with VA facilities the health records necessary for the treatment of a
recovering servicemember's current condition. As a result,
servicemembers' and veterans' complete health records are not always
shared between departments when transferring facilities, and
ultimately, the responsibility to collect and provide a complete
health record to the VA facility can fall on the recovering
servicemember and veteran.[Footnote 39] A VA official told us that
this process can be complicated because DOD separately maintains
servicemembers' inpatient, outpatient, and behavioral health records
and does not have a single database that can identify all of the
medical facilities where a servicemember received treatment. Further,
according to VA and DOD officials, delaying the collection and
assembly of a servicemember's complete medical history until the start
of the disability process could result in servicemembers having to be
reexamined when they are demobilized, needing to establish that their
injuries were connected to their time in the military, thus possibly
delaying a servicemember's or veteran's receipt of VA benefits.
Both departments have needed to create programs and provide staff to
assist recovering servicemembers during their transition from a DOD
MTF to a VAMC. For example, VA Liaisons and DOD nurse case managers
help recovering servicemembers transition from DOD to VA by assembling
their health records and sharing them with the VAMC where the
servicemember will be receiving treatment. According to DOD and VA
staff that assist servicemembers in their transition from one system
to another, DOD nurse case managers at installations that do not have
VA Liaisons do not always have the same knowledge of VA services and
benefits, and may not be informed of the appropriate referral methods
or contacts used by VA Liaisons to provide a servicemember with a
seamless transition to a VAMC. A DOD official told us that at
locations where the VA Liaison program is not available, the
transition process for recovering servicemembers from DOD to VA is
more difficult. This official understood how to properly transfer
servicemembers' records from the DOD facility to the receiving VA
facility only because of past VA experience.
DOD and VA Have Not Fully Resolved Long-standing Problems Due to
Deficiencies in Leadership and Oversight, Resources, and Collaboration:
Lack of Leadership and Oversight Has Limited DOD's and VA's Ability to
Effectively Manage Programs for Recovering Servicemembers and Veterans:
The lack of leadership and program oversight has limited DOD's and
VA's ability to effectively manage programs created to serve
recovering servicemembers and veterans. Two bodies established to
oversee these programs, the Senior Oversight Committee and the Office
of Wounded Warrior Care and Transition Policy (WWCTP),[Footnote 40]
lacked consistent leadership attention and oversight capabilities. In
addition, DOD does not have a central office that oversees or collects
common data on the military services' wounded warrior programs.
Strength of Senior Oversight Committee Leadership Waned:
Before the Senior Oversight Committee was consolidated into the Joint
Executive Council[Footnote 41] in early 2012, it had already lost many
of the characteristics that had made it a strong decision making and
oversight body for the programs and initiatives created to assist
recovering servicemembers and veterans. What had originally made it
strong were:
* high-level leadership participation without substitution of lower-
ranking officials,
* rapid policy development and quick decision making, and:
* rigorous monitoring to hold the military services and the two
departments accountable for needed actions.
Sustaining the Senior Oversight Committee's original momentum over
time became difficult, and its waning influence and effectiveness
became evident in a number of ways:
* Starting in December 2008, the Senior Oversight Committee
experienced leadership changes, including the departure of its
cochairs, the Deputy Secretaries,[Footnote 42] as well as turnover in
some of its key staff. According to a former Senior Oversight
Committee executive, the personal commitment and strong relationship
between the Deputy Secretaries who initially cochaired the Senior
Oversight Committee served as a unifying and confidence building force
that was not replicated by subsequent leadership, while leadership
turnover in the DOD offices supporting the Senior Oversight Committee
negatively impacted its ability to function effectively.
* As we have previously reported, the Senior Oversight Committee also
began to encounter challenges when DOD "disrupted the unity of
command" by changing the organizational structure of the committee and
realigning and incorporating the committee's staff and
responsibilities into existing or newly created DOD and VA offices,
such as WWCTP.[Footnote 43] Officials formerly involved with the
committee told us that the new staffing arrangement did not adequately
support the committee's efforts, and VA did not provide full-time
staff members to support the committee, as it had in the past. Later
in October 2008, VA established the Office of VA/DOD Collaboration
Services, and VA supported Senior Oversight Committee efforts, along
with broader collaboration efforts, through this separate office.
* The committee began meeting less frequently. For example, in
contrast to weekly meetings held during its initial year of operation,
in fiscal year 2011, the committee met less than 11 hours in total.
* Top DOD leadership no longer consistently attended Senior Oversight
Committee meetings. According to a former Senior Oversight Committee
official, the second Deputy Secretary of Defense to cochair the
committee sent the Deputy Undersecretary of Defense for Personnel and
Readiness to represent DOD in his place.
* The Senior Oversight Committee no longer made relatively quick
decisions. According to former Senior Oversight Committee executive
and support staff, frequent substitutions by lower-ranking officials
at Senior Oversight Committee meetings no longer allowed for quick
decision making and transformed Senior Oversight Committee meetings
into informational briefings.
* The Senior Oversight Committee no longer tracked or monitored
progress of its policy initiatives or assigned tasks. According to a
former LOA cochair and a cognizant support staff member, by 2011 the
Senior Oversight Committee was no longer routinely using a tracking
mechanism to hold the departments accountable for completing appointed
tasks. Later that year, the Recovering Warrior Task Force reported
that the Senior Oversight Committee no longer had a formal mechanism
for assessing the status of the committee's initiatives and goals,
leaving no way to determine whether initiatives or goals had been
partially or fully implemented or met.
In its September 2011 report, the Recovering Warrior Task Force
recommended combining the Senior Oversight Committee and Joint
Executive Council to improve effectiveness and reduce redundancies as
both entities had similar membership and operating structures. In
January 2012, the Joint Executive Council cochairs agreed to
consolidate the two groups. The Senior Oversight Committee's working
groups for care coordination and the integrated disability evaluation
system were realigned within the Joint Executive Council, and a
Wounded, Ill, and Injured Council was established under the Joint
Executive Council to oversee emerging issues for recovering
servicemembers and veterans.
Whether the Joint Executive Council can effectively address the issues
once managed by the Senior Oversight Committee has yet to be seen.
Several DOD and VA officials expressed concern to us about the ability
of the Joint Executive Council to focus on rapid, short-term policy
decision making rather than the longer-term strategic planning role
that it has traditionally played. For example, according to a DOD
official, historically, the Joint Executive Council has not been able
to drive policy decision making, and therefore, issues that should
have been decided by the Joint Executive Council were taken directly
to the Secretaries for resolution, raising doubts about the ability of
the Joint Executive Council to function effectively. A former Senior
Oversight Committee executive noted that the Joint Executive Council
cochairs are not of equivalent rank, another challenge that may serve
as a barrier to the council's ability to make decisions and drive
policy changes. Specifically, the VA cochair is the Deputy Secretary,
who has control over all relevant offices within VA, while the DOD
cochair is the Deputy Undersecretary of Defense for Personnel and
Readiness, whose responsibilities include establishing health and
benefit policies affecting recovering servicemembers and directing the
military services to comply with such policies but lacks authority in
enforcing the military services' implementation of these policies. The
Recovering Warrior Task Force also cited concerns about the rank of
the DOD cochair of the Joint Executive Council, stating that a higher
level of leadership is needed to sustain departmental attention on key
initiatives such as IDES and electronic health records.[Footnote 44]
Furthermore, as of August 2012, DOD officials told us that the Joint
Executive Council is operating under the original procedures that were
in place prior to the entities merging. As a result, it is unclear at
this time how the Joint Executive Council will provide oversight and
accountability for issues once addressed by the Senior Oversight
Committee.
WWCTP Lacks Authority and Leadership to Provide Oversight for Care
Coordination:
In 2008, WWCTP became responsible for overseeing the RCP among other
programs that provide assistance to recovering servicemembers.
However, WWCTP's ability to oversee the RCP, including its ability to
monitor program performance and ensure compliance with DOD policy, is
limited by its lack of operational authority, such as budget and
tasking authority, over the military services that implement the
program. According to WWCTP officials, this lack of operational
authority challenges WWCTP's ability to direct the military services
on their implementation of the program. For example, although WWCTP
has been responsible for RCP oversight since 2008, the office was not
able to collect basic program data, such as monthly enrollment
numbers, on a consistent basis until October 2011. According to a
WWCTP official, although WWCTP requested monthly data submissions from
the military services, the information was provided on an ad hoc
basis; sometimes the services would submit it, and other times they
would not. Data-collection efforts still remain a challenge for WWCTP.
For example, the Army's Wounded Warrior Program, which serves as the
Army's care coordination program, only agrees to share partial data
with WWCTP, arguing that the Army is only obligated to share data on
servicemembers served by WWCTP-contracted personnel.
Getting the military services to implement consistent care
coordination policies also poses a challenge for WWCTP. WWCTP
officials said that while WWCTP can develop policy to guide the
military services, the military services may interpret that policy and
implement their programs differently. Consequently, some DOD officials
assert that the military services have not consistently implemented
the RCP in accordance with DOD policy--an observation that is shared
by the Recovering Warrior Task Force.[Footnote 45] DOD policy requires
that care coordination should be provided to those who are "seriously"
and "severely" wounded, ill, and injured, but the Army only provides
care coordination to recovering servicemembers who are "severely"
wounded, ill, and injured.[Footnote 46] As a result, some
servicemembers who could benefit from having someone coordinate their
care and benefits as they navigate the recovery care continuum do not
have access to those services.
Some WWCTP officials with whom we spoke expressed the view that the
military services have been inconsistent in their cooperation with
WWCTP, with cooperation being better on issues that represent
priorities of top leadership. Specifically, WWCTP officials told us
that top DOD leadership has not been pressured to resolve lingering
care coordination issues as much as other more visible issues, such as
IDES and electronic medical record interoperability problems
confronting the departments. Consequently, WWCTP officials said that
the military services cooperate with WWCTP's efforts to oversee IDES
and to monitor whether the military services achieve their goals for
timely completion of the IDES process. Although these goals have not
consistently been achieved,[Footnote 47] the officials told us that
military service cooperation has not been an impediment to overseeing
IDES as it has been for overseeing care coordination. Conversely, the
military services have not been as inclined to cooperate with WWCTP on
its oversight of the RCP relative to these other issues.
In addition to limited operational authority over the military
services, turnover in leadership and other staffing changes have also
limited WWCTP's ability to provide consistent direction and oversight
for the RCP, according to WWCTP officials. Specifically:
* Three different DOD officials have led WWCTP since its inception in
2008. According to WWCTP staff, each of these officials had different
visions and priorities for the office, which led to disruptions in RCP
oversight. For example, a major oversight initiative--to collect
satisfaction survey data across the RCP--was abandoned when a new
official was appointed. In addition, the RCP has been led by three
different directors, with the most recent director leaving in June
2012.
* In September through December 2011, WWCTP's contracted staffing was
temporarily reduced by 70 percent when a contract expired and was not
immediately renewed, according to DOD. Staff reductions primarily
impacted WWCTP's ability to oversee the RCP, since many RCP support
staff members were lost. For example, according to a WWCTP official,
the office was no longer able to make monitoring visits to the RCP
program sites. However, in July 2012 a contract was awarded that
allowed WWCTP to engage additional staff to support the RCP, according
to a WWCTP official.
* In June 2012, DOD changed the name of the WWCTP office to the Office
of Warrior Care Policy and moved it under the Assistant Secretary of
Defense for Health Affairs. According to a DOD official, the change
was made as part of a realignment of DOD's organizational structure in
response to statutory requirements.[Footnote 48] An official in Health
Affairs said that the move will be beneficial because it will provide
greater access to resources, including human resources and information
technology, among others. However, it is too early to determine the
full effect of this change.
Wounded Warrior Programs Lack Central Oversight:
There is currently no central office or authority that oversees or
collects common data on the military services' wounded warrior
programs, preventing DOD from both assessing how well the programs are
working across the department and leveraging the strengths of each
program by sharing proven best practices across the military services.
Each of the military service Secretaries created their own wounded
warrior programs to meet their military service's unique needs.
Because each service developed its own policy to govern its wounded
warrior programs and no central, unified DOD policy exists to govern
these programs, no central DOD office--such as WWCTP--may direct how
these programs operate. This lack of central oversight over the
wounded warrior programs has been one of the main reasons for the
large discrepancies between these programs. The 2011 Recovering
Warrior Task Force report recommended that the Secretary of Defense
enforce the existing policy guidance regarding the Army's and Marines'
wounded warrior transition units' entrance criteria. However, in its
response to this recommendation, DOD supported the military service
Secretaries' discretion in establishing their own policies in this
regard, saying that there is no central DOD policy on the
establishment of transition units and entrance criteria, and that the
policies were established by the Secretaries for their specific
populations.
While no common data are collected on the performance of wounded
warrior programs across the military services, each individual program
has initiated internal efforts to collect and analyze performance
data. The type and quality of data vary by program, however. For
example, the largest of the wounded warrior programs, the Army Warrior
Care and Transition Program, has collected wounded warrior program
performance survey data on a continuous basis since March 2007 and has
developed outcome measures to determine the impact of its services.
However, smaller programs, such as the Air Force Wounded Warrior
Program and the United States Special Operations Command's Care
Coalition have measured baseline program satisfaction levels, but they
do not have additional years of survey data to monitor any changes
over time. (See table 3 for information about the types of performance
data collected by each of the wounded warrior programs.)
Table 3: Military Services' Wounded Warrior Program Efforts to Measure
Program Performance:
Army:
Military services' wounded warrior program: Army Warrior Care and
Transition Program;
Satisfaction surveys: Measures customer satisfaction with program:
[Check];
Performance metrics: Measures whether program meets target output
goals: [Check];
Outcome measures: Measures whether program achieves desired impact:
[Check].
Military services' wounded warrior program: Army Wounded Warrior
Program;
Satisfaction surveys: Measures customer satisfaction with program:
[Check];
Performance metrics: Measures whether program meets target output
goals: [Check];
Outcome measures: Measures whether program achieves desired impact:
[Check].
Navy/Coast Guard:
Military services' wounded warrior program: Navy Safe Harbor Program;
Satisfaction surveys: Measures customer satisfaction with program:
[Check];
Performance metrics: Measures whether program meets target output
goals: [Check];
Outcome measures: Measures whether program achieves desired impact:
[Empty].
Air Force:
Military services' wounded warrior program: Air Force Wounded Warrior
Program;
Satisfaction surveys: Measures customer satisfaction with program:
[Check][A];
Performance metrics: Measures whether program meets target output
goals: [Empty];
Outcome measures: Measures whether program achieves desired impact:
[Empty].
Military services' wounded warrior program: Air Force Recovery Care
Program;
Satisfaction surveys: Measures customer satisfaction with program:
[Check][A];
Performance metrics: Measures whether program meets target output
goals: [Check];
Outcome measures: Measures whether program achieves desired impact:
[Empty].
Marines Corps:
Military services' wounded warrior program: Marine Wounded Warrior
Regiment;
Satisfaction surveys: Measures customer satisfaction with program:
[Check];
Performance metrics: Measures whether program meets target output
goals: [Check];
Outcome measures: Measures whether program achieves desired impact:
[Check].
United States Special Operations Command:
Military services' wounded warrior program: United States Special
Operations Command's Care Coalition;
Satisfaction surveys: Measures customer satisfaction with program:
[Check];
Performance metrics: Measures whether program meets target output
goals: [Check][B];
Outcome measures: Measures whether program achieves desired impact:
[Empty].
Source: GAO analysis of interviews with military services' wounded
warrior program officials and program documentation.
[A] Although the Air Force Wounded Warrior and Recovery Care Programs'
initial satisfaction survey was completed in October 2011, the survey
results have not been released as of August 9, 2012.
[B] The United States Special Operations Command's Care Coalition has
performance metrics for its Recovery Program.
[End of table]
Some DOD officials with whom we spoke questioned why common measures
have not been developed. For example, a DOD official in charge of
wounded warrior care at an MTF suggested developing a measurement tool
to determine what aspects of the programs help recovering
servicemembers. Another DOD official involved with wounded warrior
program performance measurement commented that it is common practice
for DOD to share performance measurement practices and standard
metrics across the military services.
In September 2011, citing wide disparity across the military services
in their implementation of wounded warrior programs and policies, the
Recovering Warrior Task Force made four recommendations for creating
common standards to ensure parity in the programs and services
provided to recovering servicemembers across DOD.[Footnote 49] For
example, the first recommendation called for a common nomenclature, or
consistent definitions to be used in DOD policy to identify recovering
servicemembers who may require and be eligible for assistance. The
task force concluded that common definitions are needed to promote
consistent levels of care among the military services and would better
enable DOD to compare across programs and identify best practices. In
its response to the task force, DOD acknowledged that some of these
recommendations were valid and that DOD should take actions to address
them. However, at the time of the Recovering Warrior Task Force's 2012
report, these recommendations had not been implemented, and the task
force is continuing to follow DOD's efforts to implement
them.[Footnote 50] Moreover, even if DOD decided to take some actions
in this regard, it is unclear who would have responsibility for
addressing them, since there is no central oversight office or
authority for these programs.
Insufficient Staffing and Budget Control Have Contributed to DOD's and
VA's Inability to Resolve Delays with Disability Determinations and
Electronically Share Health Records:
In addition to problems with leadership and oversight of care
coordination and case management programs, DOD and VA have a
longstanding track record of insufficient staffing to address delays
in disability determinations and insufficient staffing and control
over the budget to oversee the development of systems with improved
capabilities for electronically sharing health records.[Footnote 51]
Insufficient Staffing Contributed to Delays in Disability
Determinations:
Insufficient staffing across both departments has affected DOD's and
VA's ability to reduce disability determination delays and meet their
IDES timeliness goals. We raised concerns about staffing in 2010, when
we reported that DOD and VA did not sufficiently staff many key
positions in the IDES process, including DOD board liaisons, who
counsel servicemembers and ensure that documentation submitted for
consideration is complete and accurate, and medical evaluation board
physicians, who review medical and service records to identify
conditions that limit a servicemember's ability to serve in the
military.[Footnote 52] In 2012, we continued to report evidence of
staffing shortages, including high caseloads for DOD board liaisons
and VA case managers as well as insufficient numbers of physicians to
write narrative summaries needed to complete the medical evaluation
board stage of the IDES process in a timely manner.[Footnote 53] Some
recovering servicemembers told us they do not receive sufficient
support from their DOD board liaisons, and that there are not enough
liaisons to efficiently meet the needs of all the recovering
servicemembers going through the IDES process.
Delays in the disability determination process are expected to
continue. VA anticipates a much larger caseload of all disability and
other benefit claims in the near future, not just those claims
associated with IDES cases. Specifically, a high-level VA official
told us that new laws, such as the Veterans Opportunity to Work Act,
[Footnote 54] will encourage all transitioning servicemembers--not
just those going through the IDES process--to claim VA benefits. This
official also told us that DOD and VA have a much larger problem to
address as a surge of 300,000 servicemembers begin to transition into
the VA system as troops return home from Iraq and Afghanistan. Without
adequate planning and adequate resources, these servicemembers may
experience much longer processing times in the disability benefits
systems.
DOD and VA are working to address staffing challenges in some of the
IDES processes that are most delayed. We have previously reported that
the Army, for example, is in the midst of a major hiring initiative to
increase staffing dedicated to its medical evaluation boards, which
will include additional DOD board liaisons and medical evaluation
board physician positions.[Footnote 55] Additionally, VA officials
said that the agency has added staffing to its IDES rating sites to
handle the demand for preliminary disability ratings, rating
reconsiderations, and final benefit decisions, which has increased the
number of preliminary VA ratings completed and slightly improved
processing times. But it is too early to tell the extent to which VA's
efforts will continue to improve processing times.
Lack of Staffing and Budget Control Limited Progress on Electronic
Health Records Sharing:
The Interagency Program Office was established by law[Footnote 56] to
serve as a single point of accountability for joint DOD and VA efforts
to implement fully interoperable electronic health record systems or
capabilities, but this office was not given sufficient staffing or
budget control by DOD and VA to effectively facilitate the
departments' efforts. According to an Interagency Program Office
official, the office was never fully staffed and was challenged by a
high degree of turnover in staffing and leadership that served in a
temporary or acting capacity.
The Interagency Program Office's initial charter limited its ability
to exercise authority over DOD and VA. Specifically, the charter
stated that control of the budget, contracts, and technical
development remained wholly within the two departments' program
offices. The charter conveyed no authority in these areas to the
Interagency Program Office. As a former Interagency Program Office
official testified in July 2011, the office lacked control of
budgeting and contracting necessary to achieve its intended purpose,
and without this, it could not sufficiently oversee the departments'
efforts and compliance with the requirements in NDAA 2008.[Footnote
57] As a result, each department continued to pursue separate
strategies, rather than a unified interoperable approach, according to
this former official.
The Interagency Program Office was rechartered in October 2011 and
provided an expanded staff and new authorities under the charter,
including control over the budget. According to Interagency Program
Office officials, when hiring under the new charter is completed, the
office will have a staff of 236 personnel, more than seven times the
number of staff originally allotted to the office by DOD and
VA.[Footnote 58] In addition, the charter provides the Interagency
Program Office with the authority to lead, oversee, and manage budget
and contracting for electronic health record sharing efforts.
According to Interagency Program Office officials, budget control is
the essential component for overseeing progress and ensuring
accountability for the departments' efforts.
With the enhanced charter, as well as plans for an expanded staff to
oversee the implementation of a single joint electronic health record
system, the Interagency Program Office will have more resources to
draw upon and support department interoperability initiatives.
However, it is still too early to determine whether this investment of
resources will be sufficient to meet the office's goals for
2017.[Footnote 59] For example, despite the provision of additional
resources, Interagency Program Office officials told us that as of
July 2012, the office is staffed at approximately 48 percent and that
hiring additional staff in time to meet appointed implementation
deadlines remains one of its biggest challenges.
Despite Repeated Attempts, DOD and VA Have Failed to Effectively
Collaborate to Align Their Care Coordination Programs; New Efforts Are
Under Way:
Since the inception of the RCP in 2008, the FRCP and RCP care
coordination programs have conflicted with one another and with other
case management programs that provide services to recovering
servicemembers and veterans. Conflicting issues have arisen as to what
populations they serve, the specific services each would provide, and
when each program would get involved in the servicemembers' recovery
process. Aligning and integrating these programs with one another--
especially the FRCP with the RCP--has proven to be a major challenge
for DOD and VA. While the departments are developing an interagency
strategy for minimizing duplication between DOD's and VA's care
coordination and case management programs, the success of this effort
will depend upon achieving cooperation between the departments--which
has been elusive for many years--as well as with the military services.
With the creation of the RCP, the FRCP was no longer the single point
of contact with respect to servicemembers' care coordination, and
early on, there were concerns and some confusion about how the FRCP
and the RCP would align without creating overlapping and duplicative
services. Shortly after the RCP was established, DOD sent a report to
congressional committees outlining a medical category assignment
process that was based on the severity of each servicemember's medical
condition, along with input from the servicemember and his or her unit
commander, to determine whether servicemembers would be directed to
either the FRCP or to the RCP for care coordination services. In
concept, the medical category assignment process would have resulted
in wounded, ill, and injured servicemembers being assigned to one of
three categories: "mild," "serious," or "severe." Under this approach,
the FRCP would provide care coordination services for "severely"
wounded, ill, and injured servicemembers and the RCP would serve those
who were "seriously" wounded, ill, and injured. (See appendix II for
additional information on the intended medical category assignment
process for DOD and VA care coordination programs.)
Despite DOD's attempt to define the populations served by the FRCP and
the RCP, neither the military services' wounded warrior programs,
which implement the RCP, nor VA, which administers the FRCP,
implemented DOD's assignment process. Instead, these programs expanded
their enrollment to include both "seriously" and "severely" recovering
servicemembers and veterans, which resulted in both programs serving
the same populations, thereby setting up the likelihood of overlap and
duplication of services. As we have previously reported, this
duplication issue is compounded by the numerous other programs that
also provide services to recovering servicemembers and veterans and
have overlapping roles as well. It is not uncommon for recovering
servicemembers to be enrolled in more than one case management or care
coordination program and end up with multiple care coordinators and
case managers--each of whom develop different care plans for the same
servicemember. The care plans may even conflict with one another,
which could conceivably adversely affect the servicemember's recovery
process. In fact, in the course of previous work, we found instances
where inadequate information exchange and poor coordination between
these programs resulted not only in duplication of effort and overlap
of services, but also confusion and frustration for servicemembers and
their families.[Footnote 60] In addition, DOD and VA officials
acknowledge that the multiplicity of care coordination and case
management programs causes confusion even among members of care
coordination teams. In October 2011, we recommended that the
Secretaries of Defense and Veterans Affairs direct the Senior
Oversight Committee to expeditiously develop and implement a plan to
strengthen functional integration across all DOD and VA care
coordination and case management programs to reduce redundancy and
overlap.
Although DOD and VA have not yet aligned care coordination policy for
the FRCP and RCP, we have found indications that care coordinators and
case managers at some locations have been cooperating to some degree
and trying to work more closely with one another. In the course of our
visits to 11 DOD and VA facilities during this review, we found that
care coordinators and case managers in many locations had attempted--
with some success--to clarify their roles and to limit the degree of
overlap and duplication in the services they provide to recovering
servicemembers and veterans. However, such local attempts to improve
the degree of cooperation and coordination among the programs are not
systemic and depend on individual personalities and circumstances.
They may not be sustainable without agreement by DOD and VA and the
alignment of policy governing case management and care coordination
programs.
Another critical issue on which DOD and VA have disagreed pertains to
the stage in a servicemember's recovery when the FRCP should get
involved in the coordination of services. Because the FRCP depends on
referrals from other programs as a basis for becoming involved with
recovering servicemembers, this can be a significant issue. Currently,
neither DOD nor VA policy clearly defines when referrals are to be
made; consequently, most wounded warrior programs delay referrals to
the FRCP until it becomes clear that the servicemember will be
separated from the military. Senior DOD officials stated that wounded
warrior program officials justify this practice on the basis that
referring a recently wounded servicemember to the FRCP--a VA-operated
program--sends a negative message to a recovering servicemember that
his or her military career has ended, even though the FRCP was
designed as a joint program. Additionally, the belief among the
military that they should "take care of their own," contributes to the
reluctance to involve the FRCP. On their part, VA maintains that its
point of engagement should be in the early stage of medical treatment
to build rapport and trust and to begin coordinating the services
needed by severely wounded servicemembers.
Despite multiple efforts over the last several years to align their
care coordination and case management programs, DOD and VA have failed
to implement lasting measures to resolve underlying problems
concerning the aligning of roles and responsibilities of the FRCP,
RCP, and case management programs. Previous attempts include the
following:
* December 2010. The Senior Oversight Committee directed its case
management work group to perform a feasibility study of
recommendations on the governance, roles, and mission of DOD and VA
care coordination. However, no action was taken by the committee and
care coordination was subsequently removed from the Senior Oversight
Committee's agenda as other issues were given higher priority.
* March 2011. WWCTP sponsored a joint summit that included officials
from VA and the military services to review DOD and VA care
coordination issues. Although this collaboration resulted in the
development of five recommendations related to care coordination, no
agreement was reached by the departments to jointly implement them. A
DOD participant told us that VA did not agree with the
recommendations, and a VA official involved in the summit concurred,
alleging that the recommendations appeared to suggest eliminating
overlap and duplication between the FRCP and RCP by ending the FRCP.
* May 2011. Concerned with overlap and duplication between the DOD and
VA care coordination programs, the House Committee on Veterans
Affairs, Subcommittee on Health directed the Deputy Secretaries of DOD
and VA to provide an analysis of how the FRCP and RCP could be
integrated under a "single umbrella" by June 20, 2011. In the absence
of such a response, the subcommittee scheduled a congressional hearing
and requested that options for addressing this issue be presented.
Following the notification of the hearing, the departments developed a
joint letter and submitted it to the subcommittee in September 2011.
This letter, however, did not identify or outline options for aligning
the FRCP and the RCP. In a hearing held by the subcommittee in early
October 2011, neither VA nor DOD outlined definitive plans to address
this issue.
* September 2011. The Recovering Warrior Task Force issued the first
of four annual reports that included 21 recommendations, including a
recommendation that the roles of care coordinators be clarified. In
DOD's official response to congressional committees, the Under
Secretary of Defense stated that the department would implement the
Recovering Warrior Task Force's recommendations. However, a Recovering
Warrior Task Force member stated that the Recovering Warrior Task
Force concluded that in most cases DOD has not made significant
changes to its programs to achieve the outcomes intended by the
recommendations. In August 2012, the Recovering Warrior Task Force
reported that DOD has fully implemented only 2 of the 21
recommendations.[Footnote 61] However, a DOD official whose office is
responsible for coordinating DOD's responses to the Recovering Warrior
Task Force's recommendations stated that DOD is in the process of
addressing several more of the 2011 Recovering Warrior Task Force
recommendations.
* October 2011-April 2012. VA declined DOD's requests to discuss care
coordination and case management policy issues during this period,
according to DOD and VA senior officials, because VA had established
its own task force to conduct an internal review of its care
coordination and case management activities, including the FRCP.
[Footnote 62] After completing its initial assessment, VA briefed
WWCTP officials on the process it was using to review its care
coordination and case management activities, but chose not to discuss
realignment of the FRCP and RCP at that time, according to DOD
officials who attended this briefing. Instead, the VA Chief of Staff
said that he approached the Army's Warrior Transition Command--which
has the largest number of recovering servicemembers--to propose
developing guidelines for better integrating Army's wounded warrior
program with the FRCP, including identifying when the Army's wounded
warrior programs should refer a recovering servicemember to the FRCP,
and replacing multiple care coordination plans with a single,
comprehensive planning document. However, a high-level DOD official
criticized this initiative as a tactic to minimize central input from
the Office of the Secretary of Defense and pointed out that this
effort would result in an agreement with only a single military
branch. In contrast, VA's Chief of Staff told us that VA took this
approach in the hope that if an agreement could be reached with Army,
the other military branches would follow suit.
More recently, in May 2012, VA and DOD developed a new task force, the
VA/DOD Warrior Care and Coordination Task Force, which represents an
effort to comprehensively address problems caused by the lack of
integration between DOD's and VA's care coordination and case
management programs. The task force has developed recommendations that
are intended to achieve a coordinated, interdepartmental approach to
care coordination and case management programs, according to a task
force official. On August 10, 2012, the task force presented the
following recommendations to the Joint Executive Council for its
consideration:
* establish and charter an interagency governance structure
responsible for coordinating VA and DOD policy,
* establish and charter an interagency care coordination community of
practice,[Footnote 63]
* align the FRCP to function in a consultant and resource-facilitator
role,
* clarify the lead coordinator role and responsibilities for executing
a recovering servicemember's comprehensive plan,
* identify the business requirements for technical tools to support
the interagency comprehensive plan, and:
* accelerate existing information-sharing efforts for care
coordination.
The Joint Executive Council provisionally approved the six
recommendations, but withheld final approval pending receipt of
additional information from the task force, such as an estimate of
resources required to implement the recommendations, as well as
details of the proposed interagency governance structure. The Joint
Executive Council instructed the task force to present the additional
information to them in another decision briefing, which was scheduled
for September 20, 2012. Absent final approval from the Joint Executive
Council, the task force's next step was to hold a status briefing for
the DOD and VA Secretaries on September 10, 2012, to discuss the task
force's recommended course of action for care coordination.
Given the inability of past task forces to effect changes that better
align DOD and VA care coordination and case management policies, it is
too soon to determine the full effect of the departments' efforts to
manage care coordination services regarding outcomes for recovering
servicemembers and veterans. Although VA and DOD appear to be moving
in a positive direction on care coordination, notable barriers remain:
* There is concern as to whether the Joint Executive Council can
effectively lead the effort to realign VA's and DOD's care
coordination policy. Some high-ranking and cognizant DOD officials we
talked with expressed concerns that the recently merged Joint
Executive Council may not have the capability to effectively monitor
the actions taken by DOD and VA to implement the task force's
recommendations. Some officials we talked with viewed the council as
taking too long to resolve issues due to both the infrequency of its
meetings[Footnote 64] and the difficulties DOD and VA members have in
agreeing with one another.
* Following approval of its recommended course of action, task force
documents indicate that a detailed plan will be completed by July
2013. VA's task force cochair stated that some aspects of the planned
changes could take years to implement, particularly as they transition
existing enrollees of programs affected by significant revisions. For
example, VA intends to conduct a case-by-case review of every FRCP
enrollee before modifying the FRCP to function in a consultant and
resource-facilitator role, according to VA's Task Force cochair.
* One of the most fundamental challenges to resolving care
coordination problems is the issue of obtaining the cooperation of the
military services to implement a new approach to care coordination and
case management, especially in light of past difficulties of working
in concert with DOD and VA programs and policies. DOD and VA
leadership officials stated that even if new solutions and policies
were to be approved by the departments, changes would be made only if
the individual military services implement the new policies as
directed by the Secretary of Defense. Several DOD and VA officials
identified concurrence and support of the military services as the
most difficult element to achieve. Ultimately, the military services'
compliance with the departments' agreed-upon strategy for care
coordination and case management programs will determine how
seamlessly recovering servicemembers and veterans will be able to
navigate the recovery care continuum.
Conclusions:
The deficiencies exposed at Walter Reed in 2007 served as a catalyst
compelling DOD and VA to address a host of problems that complicate
the course of a wounded, ill, and injured servicemember's recovery,
rehabilitation, and return to active duty or civilian life. We believe
strongly and have reported already that fixing the long-standing and
complex problems highlighted in the wake of the Walter Reed media
accounts as expeditiously as possible is critical to ensuring high-
quality care for returning servicemembers and veterans. We continue to
believe that the departments' success ultimately depends on sustained
attention, systematic oversight, and sufficient resources from both
DOD and VA. However, this has not yet occurred, and as a result, after
5 years, recovering servicemembers and veterans are still facing
problems as they navigate the recovery care continuum, including
access to some of the programs designed to assist them. The transition
period from DOD's to VA's health care system is particularly critical,
as servicemembers continue to experience delays in the disability
evaluation system and the departments continue to use methods other
than a common information technology system to share servicemembers'
health information. Until these problems are resolved, recovering
servicemembers and veterans may still face difficulties getting the
services they need to maximize their potential when they return to
active duty or transition to civilian life.
Initially, departmental leadership exhibited focus and commitment--
through the Senior Oversight Committee--to addressing problems related
to case management and care coordination, disability evaluation
systems, and data sharing between DOD and VA. However, over time,
waning leadership attention, a failure to oversee critical wounded
warrior functions and programs, limited resources, and the inability
to achieve a collaborative environment--particularly with care
coordination--have impeded the departments' ability to fully resolve
these problems. A key element in resolving current care coordination
issues in particular is eliciting the cooperation of the military
services, which are responsible for implementing various wounded
warrior programs and ensuring that these programs operate as intended--
which has sometimes not been the case, as with the RCP. Also, absent
clear direction and central oversight and accountability among the
military services' wounded warrior programs, true cooperation and
program effectiveness may be in jeopardy.
We believe that at the heart of the problem is the need for strong and
unwavering leadership to bring about changes that best serve our
nation's recovering servicemembers and veterans. This leadership
should be united across both DOD and VA and centered on the individual
servicemember's or veteran's recovery. Many task forces--including the
VA/DOD Warrior Care and Coordination Task Force and the Recovering
Warrior Task Force--have already attempted to bring a spirit of
cooperativeness and clear direction and purpose among the different
programs providing services to this population. However, to date,
these efforts have not fully resolved key issues, and our nation's
recovering servicemembers and veterans continue to face obstacles and
challenges, especially as they transition from DOD's to VA's health
care system. Certainly, the fluidity and focus of the departments'
leadership over the last several years, especially related to care
coordination, have added to the challenges of developing consistent
policy, effective oversight, and mechanisms to monitor progress and
hold programs accountable. The departments have recently taken steps
to improve problems related to care coordination, disability
evaluations, and the electronic sharing of health records, through
concerted efforts to coordinate on policy, increase staffing
resources, and provide control over the budget, respectively. However,
it is too early to determine the effectiveness of these efforts, and
sustained leadership attention will be critical to their success. The
need to fully resolve remaining problems is urgent as there will be an
increasing demand for services from both DOD and VA as the current
conflicts come to an end. If not resolved now, these same problems
will persist into the future for recovering servicemembers and
veterans.
Recommendations for Executive Action:
To ensure that servicemembers have equitable access to the military
services' wounded warrior programs, including the RCP, and to
establish central accountability for these programs, we recommend that
the Secretary of Defense establish or designate an office to centrally
oversee and monitor the activities of the military services' wounded
warrior programs to include the following:
* Develop consistent eligibility criteria to ensure that similarly
situated recovering servicemembers from different military services
have uniform access to these programs.
* Direct the military services' wounded warrior programs to fully
comply with the policies governing care coordination and case
management programs and any future changes to these policies.
* Develop a common mechanism to systematically monitor the performance
of the wounded warrior programs--to include the establishment of
common terms and definitions--and report this information on a
biannual basis to the Armed Services Committees of the House of
Representatives and the Senate.
To ensure that persistent challenges with care coordination,
disability evaluation, and the electronic sharing of health records
are fully resolved, we recommend that the Secretaries of Defense and
Veterans Affairs ensure that these issues receive sustained leadership
attention and collaboration at the highest levels with a singular
focus on what is best for the individual servicemember or veteran to
ensure continuity of care and a seamless transition from DOD to VA.
This should include holding the Joint Executive Council accountable
for:
* ensuring that key issues affecting recovering servicemembers and
veterans get sufficient consideration, including recommendations made
by the Warrior Care and Coordination Task Force and the Recovering
Warrior Task Force;
* developing mechanisms for making joint policy decisions;
* involving the appropriate decision-makers for timely implementation
of policy; and:
* establishing mechanisms to systematically oversee joint initiatives
and ensure that outcomes and goals are identified and achieved.
Agency Comments and Our Evaluation:
DOD and VA reviewed a draft of this report and provided comments,
which are reprinted in appendixes III and IV. DOD and VA also provided
technical comments, which we incorporated as appropriate.
DOD concurred with specific components of our first recommendation
regarding the establishment of central accountability for the military
services' wounded warrior programs. In particular, DOD agreed that a
single office should have oversight responsibility for the military
services' wounded warrior programs and that these programs should
fully comply with the policies governing care coordination and case
management programs and any future changes to these policies.
However, DOD only partially concurred with other components of our
first recommendation--that DOD develop consistent eligibility criteria
for enrollment in wounded warrior programs and that DOD establish a
common mechanism to systematically monitor the performance of these
programs. In its comments, DOD explained that the three military
service Secretaries should have the ability to control entrance
criteria into their wounded warrior programs and added that it does
not believe that differences in eligibility criteria for these
programs results in noticeable differences in access to these programs
by recovering servicemembers or their families. DOD did not offer a
rationale, however, as to why the military service Secretaries should
unilaterally determine eligibility criteria for their wounded warrior
programs, other than to suggest that flexibility is important and
necessary. Moreover, as we have reported, DOD does not systematically
assess or monitor these programs across the department, and as a
result, we believe that DOD has no basis to assert that there are no
noticeable differences in access to these programs. Overall, we
believe that similarly situated wounded, ill, and injured
servicemembers should be given the same access to wounded warrior
programs and the assistance these programs provide, regardless of
their branch of military service.
With respect to developing a common mechanism to systematically
monitor the performance of the wounded warrior programs, DOD responded
that the Interagency Care and Coordination Committee will conduct an
inventory of all wounded warrior programs to identify duplication and
areas for gaining efficiencies. In commenting on our recommendation to
also report its performance information on the wounded warrior
programs to the Armed Services Committees on a biannual basis, DOD
stated that the department reports progress through the Joint
Executive Council's annual strategic planning report and any
additional reporting would be redundant and of limited value. We
disagree. The Joint Executive Council's strategic planning and annual
reports focus on joint efforts between the departments and do not
report on the performance of the military services' wounded warrior
programs. Therefore, we do not believe that the performance
information on the wounded warrior programs would be redundant or of
limited value given that the department itself is currently unable to
systematically determine how well these programs are functioning. As
we reported, one of the key problems hindering a department-wide
assessment of these programs is the lack of common terms and
definitions used by the military services. Although DOD acknowledges
that this is an issue, it asserts that it has instituted some common
definitions through the Senior Oversight Committee and through its
instruction for the RCP and that it will work towards a common
understanding and use of these approved definitions. Although we are
aware of efforts to define some terms, on the basis of our work, it
does not appear that the military services are using them
consistently. Therefore, substantial progress towards a common
understanding and use will be critical to the department's ability to
oversee these programs.
DOD did not respond directly to our recommendation for developing a
common mechanism for performance measurement, which we found is not
systematically conducted across the wounded warrior programs. During
our collection of performance data from the wounded warrior programs,
we found that the programs vary in their ability to report performance
outcome measures on the basis of what each program chooses to track.
In addition, we found that some of the programs had difficulty
reporting basic data, such as enrollment numbers, and only compiled
these data following our request--sometimes taking about 5 months to
do so. Lastly, our recommendation is consistent with the call of the
Interagency Care and Coordination Committee that the military programs
develop more useful quantitative and qualitative metrics that would
effectively demonstrate their performance. Until DOD takes the
necessary steps to assess these programs department-wide, it will
never know with certitude whether these programs are meeting the needs
of its recovering servicemember population.
DOD and VA both concurred with our second recommendation that the
departments ensure that care coordination, disability evaluation, and
electronic health record sharing receive sustained leadership
attention and collaboration at the highest levels, with a singular
focus on what is best for the individual servicemember or veteran to
ensure continuity of care and a seamless transition from DOD to VA.
In addition to its comments on our recommendation, VA asserted that
the care coordination challenges facing both departments are broader
and more complex than issues concerning just the FRCP and RCP and that
our overall analysis and conclusions are over simplified. VA stated
that through its recently formed task force, both departments
identified over 40 programs that provide some level of coordination or
management of care and services across the continuum of care and
acknowledged that there is no common operational picture that
facilitates collaborative planning or situational awareness. We agree
that the care coordination challenges are broader and more complex
than the FRCP and RCP. Specifically, in October 2011, we recommended
that the departments strengthen functional integration across all care
coordination and case management programs to reduce redundancy and
overlap.[Footnote 65] Similarly, our current recommendation is broad
and does not focus exclusively on these two programs as our review
also included other programs, such as the military services' wounded
warrior programs, VA's Liaison for Healthcare Program, and VA's
OEF/OIF/OND Care Management Program. The scope of our review was
directed by Congress, who required us to report on the progress DOD
and VA in implementing the programs involved with the care,
management, and transition of wounded, ill, and injured servicemembers
that they established. Our specific discussion of the FRCP and RCP
served to illustrate, until recently, a continued lack of
collaboration between the departments to better align these programs
and better serve recovering servicemembers and veterans. Furthermore,
during detailed discussions with top-level VA and DOD officials, they
focused on the FRCP and RCP issue as the main sticking point in
achieving coordination and cooperation among the two departments with
respect to care coordination and case management. We are encouraged
that the departments are now taking steps to identify all programs
that need better alignment and integration. However, as we have
stated, the key to resolving this and other problems is the need for
strong and unwavering leadership that is united across both
departments and focused on the individual servicemember's or veteran's
recovery.
VA also suggested further clarifications to our report.
* VA suggested that we clarify that while the VA Liaison for
Healthcare Program facilitates the transfer of recovering
servicemembers from DOD's to VA's health care system, it is a DOD or
VA treatment team that determines if the servicemember is medically
ready to begin the transition process. VA also suggested that we add
that the OEF/OIF/OND Care Management Program screens all returning
combat veterans for case management services. We incorporated VA's
suggested changes.
* VA disagrees with a DOD-attributed statement that the Joint
Executive Council historically has not driven policy decision making
and that, at times, decisions were taken directly to the DOD and VA
Secretaries for resolution. The statement that we attribute to the DOD
official relates to the period prior to the integration of the Senior
Oversight Committee with the Joint Executive Council. As mentioned in
the report, it is too early to ascertain whether the newly merged
Joint Executive Council will be able to make decisions and drive
policy changes in DOD and VA.
* VA provided clarification about how the Joint Executive Council is
currently providing oversight and accountability for wounded warrior
issues that were once addressed by the Senior Oversight Committee. We
recognize the effort that the Joint Executive Council is now making to
track wounded warrior issues, including the integrated disability
evaluation system and care coordination. However, we have not had the
opportunity to review this tracking mechanism now in place to comment
on its effectiveness.
* VA asserts that the size of the overlap between the FRCP and RCP
population is fairly small. Although the number of seriously injured
servicemembers may be comparatively small, this situation has been and
continues to be a major concern in that these individuals and their
families represent a highly vulnerable population. Further, during our
review, one high-level DOD official we spoke with characterized the
FRCP/RCP overlap as the most difficult policy issue to resolve. While
we understand that DOD and VA now intend to harmonize care
coordination policies within a broader context of interdepartmental
care coordination and case management practice, many of the proposed
revisions--including the role to be played by the FRCP--are neither
fully developed nor implemented by the separate DOD and VA programs at
this time.
* In our report, we explain that VA declined DOD's requests to discuss
care coordination and case management policy issues--for the better
part of 1 year--on the basis that VA was conducting an internal review
of its care coordination and case management activities. In its
comments, VA stated that the use of the word "decline" is misleading,
and suggested that we change our text to state that VA asked DOD to
defer collaboration until the internal review was conducted. Despite
VA's characterization that our statement is misleading, we maintain
that this finding was based on remarks made by high-level DOD
officials that were subsequently corroborated by senior VA officials.
We are sending copies of this report to appropriate congressional
committees, the Secretary of Defense, the Secretary of Veterans
Affairs, and other interested parties. The report also is available at
no charge on GAO's website at [hyperlink, http://www.gao.gov].
If you or your staff members have any questions about this report,
please contact me at (202) 512-7114 or williamsonr@gao.gov. Contact
points for our Offices of Congressional Relations and Public Affairs
may be found on the last page of this report. Key contributors to this
report are listed in appendix V.
Signed by:
Randall B. Williamson:
Director, Health Care:
List of Committees:
The Honorable Carl Levin:
Chairman:
The Honorable John McCain:
Ranking Member:
Committee on Armed Services:
United States Senate:
The Honorable Patty Murray:
Chairman:
The Honorable Richard Burr:
Ranking Member:
Committee on Veterans' Affairs:
United States Senate:
The Honorable Daniel Inouye:
Chairman:
The Honorable Thad Cochran:
Ranking Member:
Subcommittee on Defense:
Committee on Appropriations:
United States Senate:
The Honorable Tim Johnson:
Chairman:
The Honorable Mark Kirk:
Ranking Member:
Subcommittee on Military Construction, Veterans Affairs, and Related
Agencies:
Committee on Appropriations:
United States Senate:
The Honorable Howard McKeon:
Chairman:
The Honorable Adam Smith:
Ranking Member:
Committee on Armed Services:
House of Representatives:
The Honorable Jeff Miller:
Chairman:
The Honorable Bob Filner:
Ranking Member:
Committee on Veterans' Affairs:
House of Representatives:
The Honorable C.W. Bill Young:
Chairman:
The Honorable Norman Dicks:
Ranking Member:
Subcommittee on Defense:
Committee on Appropriations:
House of Representatives:
The Honorable John Culberson:
Chairman:
The Honorable Sanford Bishop:
Ranking Member:
Subcommittee on Military Construction, Veterans Affairs, and Related
Agencies:
Committee on Appropriations:
House of Representatives:
[End of section]
Appendix I: Enrollment and Populations for Select Department of
Defense and Department of Veterans Affairs Programs:
Both the Department of Defense (DOD) and the Department of Veterans
Affairs (VA) operate care coordination[Footnote 66] and case
management[Footnote 67] programs designed to assist servicemembers and
veterans as they navigate the recovery care continuum, from acute
medical treatment and stabilization, through rehabilitation, to
reintegration--either back to active duty or to the civilian community
as a veteran. This appendix describes selected DOD and VA programs and
includes data on enrollment and population characteristics as well as
the type of information each program tracks on referrals.
DOD Wounded Warrior Programs:
Within DOD, each military service has established its own wounded
warrior program or a complement of programs[Footnote 68] to assist
wounded, ill, and injured servicemembers during their recovery and
rehabilitation, and to help with the transition back to active duty or
to civilian life.[Footnote 69] Wounded warrior programs range in size
from the largest, the Army's Warrior Transition Units and Community-
Based Warrior Transition Units, with 18,762 enrollees served in fiscal
year 2011, to the smallest, the Navy Safe Harbor Program, with 784
enrollees served in fiscal year 2011. (See table 4 for a list of the
DOD wounded warrior programs and enrollment for fiscal year 2011.)
Table 4: Military Services' Wounded Warrior Programs: Enrollment for
Fiscal Year 2011:
Army:
Military services' wounded warrior program: Army Warrior Care and
Transition Program: Warrior Transition Units and Community-Based
Warrior Transition Units[A,B];
Number enrolled, as of fiscal year 2011:
18,762.
Military services' wounded warrior program: Army Warrior Care and
Transition Program: Army Wounded Warrior Program[B];
Number enrolled, as of fiscal year 2011: 9,738.
Navy/Coast Guard:
Military services' wounded warrior program: Navy Safe Harbor
Program[C];
Number enrolled, as of fiscal year 2011: 784.
Air Force:
Military services' wounded warrior program: Air Force Wounded Warrior
Program[D];
Number enrolled, as of fiscal year 2011: 1,386.
Military services' wounded warrior program: Air Force Recovery Care
Program;
Number enrolled, as of fiscal year 2011: 1,804.
Marines Corps:
Military services' wounded warrior program: Marine Wounded Warrior
Regiment[E,F];
Number enrolled, as of fiscal year 2011: 2,155.
United States Special Operations Command:
Military services' wounded warrior program: United States Special
Operations Command's Care Coalition;
Number enrolled, as of fiscal year 2011: 4,570.
Source: GAO analysis of military services' wounded warrior program
information.
[A] Enrollment data include servicemembers who were in the Army
Warrior Care and Transition Program at any point during the fiscal
year, not the population on a specific date.
[B] Enrollees may include servicemembers who are dually enrolled in
the Army Warrior Care and Transition Program and Army Wounded Warrior
Program.
[C] Enrollment numbers represent all enrollees being served by the
program as of December 31, rather than as of the end of each fiscal
year.
[D] Servicemembers may be dually enrolled in the Air Force Wounded
Warrior Program and the Air Force Recovery Care Program. The
enrollment data presented here only reflect servicemembers who are
enrolled in the Air Force Wounded Warrior Program.
[E] According to a Wounded Warrior Regiment official, the Wounded
Warrior Regiment does not have "enrollees," rather the program assigns
and attaches Marines to the program.
[F] Total enrollment does not include Wounded Warrior Regiment
enrollees who are not assigned or attached to a Wounded Warrior
Regiment site. Many wounded, ill, and injured Marines are supported by
the Wounded Warrior Regiment while remaining with their parent unit.
[G] Enrollees of the United States Special Operations Command's Care
Coalition Recovery Program may also be enrolled in a military
service's wounded warrior program on the basis of their branch of
service, but the United States Special Operations Command's Care
Coalition Recovery Program takes the lead for providing nonclinical
case management.
[End of table]
Programs differ in their organization and function. For example, two
of the wounded warrior programs--the Army's Warrior Transition Units
and the Marine Corps Wounded Warrior Regiment--are organized under
separate military commands, which means that wounded, ill, and injured
servicemembers enrolled in these programs may be removed from their
parent units or commands and assigned or attached to a separate unit
or regiment that provides command and control[Footnote 70] over the
recovering servicemember as well as administrative support. These
servicemembers may be housed in separate barracks while receiving
medical care and waiting to transition back to active duty or civilian
life. The other wounded warrior programs do not assign or attach
servicemembers to a separate command structure, but provide services
while recovering servicemembers remain with their parent units. The
services provided by the wounded warrior programs also vary. A
servicemember may receive either case management or care coordination
services or both, depending on how the military service's wounded
warrior program is structured. For example, the Navy Safe Harbor
Program only provides care coordination services and does not have a
case management component, whereas the Marine Corps Wounded Warrior
Regiment provides all servicemembers with both case management and
care coordination services. A further distinction is whether or not a
program serves veterans as well as servicemembers. For example, the
Army Warrior Transition Units do not serve veterans, but eligible
veterans are served through the Army Wounded Warrior Program. The
remainder of the wounded warrior programs continue to provide support
to any enrollee who needs services even after the enrollee has
transitioned to veteran status.
Army Warrior Care and Transition Program:
The Army's Warrior Care and Transition Program, which was established
in May 2007,[Footnote 71] consists of two components that support the
recovery process for wounded, ill, and injured servicemembers--the
Warrior Transition Units[Footnote 72] and the Army Wounded Warrior
Program. The Army operates a number of warrior transition units
located at Army installations across the country. Recovering
servicemembers who are attached or assigned to a warrior transition
unit generally are housed in barracks and receive medical care,
rehabilitative services, professional development and clinical and
nonclinical case management services in order to help them in their
transition back to active duty or to the civilian community. Army
Warrior Transition Units vary in size and functionality, including
community-based warrior transition units,[Footnote 73] which primarily
serve Reserve Component servicemembers.[Footnote 74] In fiscal year
2011, there were a total of 14,906 recovering servicemembers assigned
or attached to 29 warrior transition units and 3,856 recovering
servicemembers assigned or attached to 10 community-based warrior
transition units. (See table 5.) According to Army policy, recovering
servicemembers assigned or attached to the units are expected to
require 6 months or more of rehabilitative care or require complex
medical management.
The Army Wounded Warrior Program[Footnote 75] was established in April
2004 to assist severely wounded, ill, and injured servicemembers,
their families, and caregivers. Army Wounded Warrior Program enrollees
are assigned an Advocate who provides nonclinical care coordination
services, which include assisting enrollees with benefit information,
career guidance, finances, and the integrated disability evaluation
system (IDES) process. Recovering servicemembers are eligible for Army
Wounded Warrior Program services if they have, or are expected to
receive, an Army disability rating of 30 percent or greater in one or
more specific categories or a combined rating of 50 percent or greater
for conditions that are the result of combat or are combat-related.
The most severely wounded, ill, or injured servicemembers who are
assigned to warrior transition units are also enrolled in the Army
Wounded Warrior Program. The Army Wounded Warrior Program also
provides services to veterans. In fiscal year 2011, nearly three-
fourths of the population (6,953) were veterans. (See table 6.)
Table 5: Army Warrior Care and Transition Program Enrollment
Populations and Characteristics, Fiscal Years 2008 through 2011:
Program enrollment for Warrior Transition Units and Community-Based
Warrior Transition Units:
Total enrollment[A,B];
Fiscal year:
2008: 20,878;
2009: 19,238;
2010: 18,647;
2011: 18,762.
Active Duty;
Fiscal year:
2008: 13,558;
2009: 11,771;
2010: 9,560;
2011: 9,160.
National Guard[C];
Fiscal year:
2008: 4,761;
2009: 4,839;
2010: 5,860;
2011: 5,857.
Reservists[C];
Fiscal year:
2008: 2,559;
2009: 2,628;
2010: 3,227;
2011: 3,745.
Population characteristics:
Enrollees with combat-related conditions[D];
Fiscal year:
2008: 2,523;
2009: 2,033;
2010: 1,788;
2011: 1,984.
Enrollees with non-combat-related conditions[E];
Fiscal year:
2008: 18,355;
2009: 17,205;
2010: 16,859;
2011: 16,778.
Enrollees who left the program:
Returned to active duty[F];
Fiscal year:
2008: 4,366;
2009: 4,279;
2010: 4,664;
2011: 5,349.
Transitioned to veteran status[G];
Fiscal year:
2008: 5,125;
2009: 5,938;
2010: 4,027;
2011: 3,448.
Left for other reasons[H];
Fiscal year:
2008: 146;
2009: 200;
2010: 159;
2011: 148.
Referrals:
Total number of servicemembers referred to the program[I];
Fiscal year:
2008: 20,878;
2009: 19,238;
2010: 18,647;
2011: 18,762.
Warrior Transition Unit enrollment:
Total enrollment in Warrior Transition Units[A,B];
Fiscal year:
2008: 18,038;
2009: 16,203;
2010: 14,921;
2011: 14,906.
Active Duty;
Fiscal year:
2008: 13,511;
2009: 11,686;
2010: 9,456;
2011: 9,058.
National Guard[C];
Fiscal year:
2008: 2,864;
2009: 2,807;
2010: 3,336;
2011: 3,354.
Reservists[C];
Fiscal year:
2008: 1,663;
2009: 1,710;
2010: 2,129;
2011: 2,494.
Population characteristics:
Enrollees with combat-related conditions[D];
Fiscal year:
2008: 2,231;
2009: 1,798;
2010: 1,569;
2011: 1,760.
Enrollees with non-combat-related conditions[E];
Fiscal year:
2008: 15,807;
2009: 14,405;
2010: 13,352;
2011: 13,146.
Enrollees who left the program:
Returned to active duty[F];
Fiscal year:
2008: 3,613;
2009: 3,653;
2010: 3,803;
2011: 4,259.
Transitioned to veteran status[G];
Fiscal year:
2008: 4,706;
2009: 5,445;
2010: 3,700;
2011: 3,167.
Left for other reasons[H];
Fiscal year:
2008: 139;
2009: 184;
2010: 146;
2011: 135.
Community-Based Warrior Transition Unit enrollment:
Total enrollment in Community-Based Warrior Transition Units[A,B,J];
Fiscal year:
2008: 2,840;
2009: 3,035;
2010: 3,726;
2011: 3,856.
Active Duty;
Fiscal year:
2008: 47;
2009: 85;
2010: 104;
2011: 102.
National Guard[C];
Fiscal year:
2008: 1,897;
2009: 2,032;
2010: 2,524;
2011: 2,503.
Reservists[C];
Fiscal year:
2008: 896;
2009: 918;
2010: 1,098;
2011: 1,251.
Population characteristics:
Enrollees with combat-related conditions[D];
Fiscal year:
2008: 292;
2009: 235;
2010: 219;
2011: 224.
Enrollees with non-combat-related conditions[E];
Fiscal year:
2008: 2,548;
2009: 2,800;
2010: 3,507;
2011: 3,632.
Enrollees who left the program:
Returned to active duty[F];
Fiscal year:
2008: 753;
2009: 626;
2010: 861;
2011: 1,090.
Transitioned to veteran status[G];
Fiscal year:
2008: 419;
2009: 493;
2010: 327;
2011: 281.
Left for other reasons[H];
Fiscal year:
2008: 7;
2009: 16;
2010: 13;
2011: 13.
Source: GAO analysis of Army Warrior Care and Transition Program data.
Notes: The Army Warrior Care and Transition Program's Warrior
Transition Units and Community-Based Warrior Transition Units serve
Active, Guard, and Reserve Component servicemembers. The program does
not serve veterans.
[A] Enrollment data include servicemembers who were in the Army
Warrior Care and Transition Program at any point during the fiscal
year, not the population on a specific date.
[B] Enrollees may include servicemembers who are dually enrolled in
the Army Warrior Care and Transition Program and the Army Wounded
Warrior Program.
[C] National Guard and Reservists enrolled in the Army Warrior Care
and Transition Program must be on active-duty orders in order to
participate in the program.
[D] Enrollees with combat-related conditions only include those
enrollees medically evacuated from a combat zone with identified
battle injuries. Other combat-related conditions, such as
posttraumatic stress disorder, may not have required medical
evacuation from a combat zone and therefore would not be captured in
the data provided. In addition, prior battle injuries not related to
the servicemember's current medical diagnosis would also be excluded
from the data. Battle injury is defined as damage or harm sustained by
personnel during or as a result of battle conditions.
[E] Enrollees with non-combat-related conditions include all enrollees
who were not medically evacuated from a combat zone and those who are
identified as having nonbattle injuries.
[F] Enrollees who exit the program by returning to duty also include
Guard or Reserve Components who are released from active duty, but not
medically separated from military service.
[G] Enrollees who transition to veteran status include only enrollees
who are medically separated from military service.
[H] Enrollees are considered to have left the Army Warrior Care and
Transition Program's Warrior Transition Units for "other" reasons,
including death or as a result of military legal actions. This
category also includes those enrollees with incomplete information
about why they left the program.
[I] According to Army Warrior Care and Transition Program officials,
the program only tracks referral information for program enrollees.
Therefore, the program does not have data on servicemembers who were
referred, but never enrolled into the program.
[J] The Army's Community-Based Warrior Transition Units are populated
only by servicemembers who transfer to the Community-Based Units from
their original assignment to a Warrior Transition Unit. According to
Army Warrior Care and Transition Program officials, the first 60 days
of recovery are typically spent in a Warrior Transition Unit. After
the initial recovery period, a decision is made about whether the
servicemember should be transferred to a community-based unit. Data
provided in the table reflect the most recent location recorded for
each enrollee.
[End of table]
Table 6: Army Wounded Warrior Program Enrollment Populations and
Characteristics, Fiscal Years 2008 through 2011:
Program enrollment for Army Wounded Warrior Program:
Total enrollment[A,B];
Fiscal year:
2008: 3,813;
2009: 6,473;
2010: 8,454;
2011: 9,738.
Servicemembers;
Fiscal year:
2008: 2,037;
2009: 3,377;
2010: 3,354;
2011: 2,785.
Active Duty;
Fiscal year:
2008: 1,249;
2009: 2,252;
2010: 1,954;
2011: 1,210.
National Guard[C];
Fiscal year:
2008: 562;
2009: 794;
2010: 985;
2011: 1,091.
Reservists[C];
Fiscal year:
2008: 226;
2009: 331;
2010: 415;
2011: 484.
Veterans;
Fiscal year:
2008: 1,776;
2009: 3,096;
2010: 5,100;
2011: 6,953.
Population characteristics:
Enrollees with combat-related conditions;
Fiscal year:
2008: 3,233;
2009: 5,503;
2010: 7,082;
2011: 8,001.
Enrollees with non-combat-related conditions;
Fiscal year:
2008: 544;
2009: 875;
2010: 1,104;
2011: 1,184.
Enrollees with conditions not classified as either combat-or non-
combat-related[D];
Fiscal year:
2008: 36;
2009: 95;
2010: 268;
2011: 553.
Enrollees who changed duty status or left the program:
Returned to active duty[E];
Fiscal year:
2008: 117;
2009: 80;
2010: 59;
2011: 47.
Transitioned to veteran status[F];
Fiscal year:
2008: 958;
2009: 1,574;
2010: 1,539;
2011: 1,100.
Left for other reasons[G];
Fiscal year:
2008: 10;
2009: 24;
2010: 21;
2011: 3.
Referrals and assists:
Total number of servicemembers referred to the program;
Fiscal year:
2008: 3,106;
2009: 4,199;
2010: 3,993;
2011: 3,364.
Servicemembers referred and enrolled in the program;
Fiscal year:
2008: 2,037;
2009: 3,377;
2010: 3,354;
2011: 2,785.
Servicemembers referred and assisted, but not enrolled in the
program[H];
Fiscal year:
2008: 969;
2009: 822;
2010: 639;
2011: 579.
Total number of veterans referred to the program;
Fiscal year:
2008: 2,568;
2009: 3,617;
2010: 5,554;
2011: 7,291.
Veterans referred and enrolled in the program;
Fiscal year:
2008: 1,776;
2009: 3,096;
2010: 5,100;
2011: 6,953.
Veterans referred and assisted, but not enrolled in the program;
Fiscal year:
2008: 792;
2009: 521;
2010: 454;
2011: 338.
Source: GAO analysis of Army Wounded Warrior Program data.
[A] Enrollment data include servicemembers and veterans who were
served by the program at any point during the fiscal year, not the
population being served on a specific date.
[B] Enrollees also may be enrolled in the Army's Warrior Transition
Units or Community-Based Warrior Transition Units.
[C] Enrollment is counted in this category only for National Guard and
Reservists who were on active duty orders during the designated fiscal
year. According to Army Wounded Warrior Program officials, National
Guard and Reservists who were demobilized previous to the designated
fiscal year are considered veterans.
[D] Enrollees considered to have "conditions not classified as either
combat-or non-combat-related" include enrollees who have yet to
complete the physical disability evaluation process and therefore do
not have verification of whether or not their conditions are combat-
related.
[E] Army Wounded Warrior Program officials said that the program does
not specifically track whether or when an enrollee returns to active
duty. However, data on duty status are available for those enrollees
who are also enrolled in the Army's Warrior Transition Units or
Community-Based Warrior Transition Unit, as provided in the table.
[F] Army Wounded Warrior Program officials said that the program does
not specifically track whether or when an enrollee transitions to
veteran status because it has no impact on enrollees' eligibility for
the program and whether they leave the program. Rather, these data
have been derived by the program by counting the number of enrolled
servicemembers who received a certificate of release or discharge from
active duty within each fiscal year.
[G] Enrollees considered to have "left for other reasons" include
those who died while enrolled in the Army Wounded Warrior Program.
[H] The data include those enrollees who were later found ineligible
for the program and were disenrolled, but assisted during their
initial period of enrollment. These ineligible enrollees were not
included in the program's count of total enrollees. Additionally, some
servicemembers who were referred to the Wounded Warrior Program and
provided short-term, informal assistance are not included in the data
because they are not tracked by the program.
[End of table]
Navy Safe Harbor Program:
The Navy Safe Harbor Program office was established in 2005. Over
time, this office expanded its reach and mission, and in 2008 the
program became responsible for nonclinical care coordination and
oversight of all severely (and high-risk nonseverely) wounded, ill,
and injured Sailors and Coast Guardsmen.[Footnote 76] Recovering
servicemembers enrolled in the program are assigned to nonmedical care
managers who are geographically dispersed at major military treatment
facilities and Veterans Affairs polytrauma medical centers. The
program's nonmedical care managers assist enrollees with services such
as pay and personnel, legal, housing, as well as education and
training benefits. In addition, enrollees obtain support from
centrally located experts in transition and benefits assistance, such
as a liaison to the Department of Labor and a Navy Staff Judge
Advocate. Recovering servicemembers enrolled in the program are
enrolled for life and, if desired, receive support from Navy Safe
Harbor personnel after they transition to veteran status. (See table
7.)
Table 7: Navy Safe Harbor Program Enrollment Populations and
Characteristics, Fiscal Years 2008 through 2011:
Program enrollment for Navy Safe Harbor Program:
Total enrollment[A];
Fiscal year:
2008: 255;
2009: 434;
2010: 576;
2011: 784.
Servicemembers[A];
Fiscal year:
2008: 144;
2009: 236;
2010: 271;
2011: 391.
Active Duty[A];
Fiscal year:
2008: 77;
2009: 129;
2010: 152;
2011: 254.
Reservists[A];
Fiscal year:
2008: 67;
2009: 107;
2010: 119;
2011: 137.
Veterans[A];
Fiscal year:
2008: 111;
2009: 198;
2010: 305;
2011: 393.
Population characteristics:
Enrollees with combat-related conditions;
Fiscal year:
2008: 130;
2009: 166;
2010: 193;
2011: 239.
Enrollees with non-combat-related conditions;
Fiscal year:
2008: 125;
2009: 268;
2010: 383;
2011: 545.
Enrollees who changed duty status or left the program:
Returned to active duty;
Fiscal year:
2008: ND;
2009: ND;
2010: ND;
2011: 113.
Transitioned to veteran status;
Fiscal year:
2008: ND;
2009: 91[B];
2010: 338[B];
2011: 142.
Left for other reasons;
Fiscal year:
2008: 0;
2009: 0;
2010: 0;
2011: 1.
Referrals and assists:
Total number of servicemembers and veterans referred to the program[C];
Fiscal year:
2008: 304;
2009: 296;
2010: 370;
2011: 475.
Servicemembers and veterans referred and enrolled in the program[C];
Fiscal year:
2008: 255;
2009: 179;
2010: 142;
2011: 208.
Servicemembers and veterans referred and assisted, but not enrolled in
the program[C];
Fiscal year:
2008: 74;
2009: 417;
2010: 330;
2011: 199.
Servicemembers and veterans referred but not enrolled in or assisted by
the program[C];
Fiscal year:
2008: 0;
2009: 0;
2010: 2;
2011: 73.
Legend: ND indicates that no data are available.
Source: GAO analysis of Navy Safe Harbor Program data.
[A] Enrollment numbers represent all enrollees being served by the
program as of December 31, rather than as of the end of each fiscal
year.
[B] According to a Navy Safe Harbor Program official, the database
used to capture information about the duty status of enrollees did not
have the ability to track dates when servicemembers transitioned to
veteran status until the system was upgraded in 2010. At that point,
the program moved all enrollees who had previously medically retired
to a veteran status. Therefore, the number of enrollees who
transitioned to veteran status in fiscal year 2010 includes both
servicemembers who transitioned to veteran status within the fiscal
year and servicemembers who transitioned to veteran status during the
previous fiscal years.
[C] The database used to capture referral information for the Navy
Safe Harbor Program does not distinguish servicemembers from veterans
referred to the program. Rather, the referral information provided for
servicemembers also includes any veterans who were referred to the
program.
[End of table]
Air Force Warrior and Survivor Care Program:
The Air Force Warrior and Survivor Care Program supports wounded, ill,
and injured servicemembers through its Air Force Wounded Warrior
Program and the Air Force Recovery Care Program.[Footnote 77] The Air
Force Wounded Warrior Program was established in June 2005 to provide
nonclinical case management to Airmen, Air National Guard, and Reserve
Component servicemembers who have combat-related illnesses or
injuries. Each enrolled servicemember is assigned a nonmedical care
manager, who serves as an advocate for enrollees to obtain services
from agencies and organizations that support the needs of enrolled
servicemembers, their families and caregivers. The Air Force Wounded
Warrior Program continues to provide services to enrollees once they
transition to veteran status. (See table 8.)
The Air Force Recovery Care Program was established in November 2008
to provide nonclinical care coordination services for seriously ill
and injured Airmen, Air National Guard, and Reserve Component
servicemembers. Each enrolled servicemember is assigned a care
coordinator who oversees the coordination of services and assists
enrollees' with nonclinical needs, such as employment and benefits.
These care coordinators also work with enrolled servicemembers to
develop their recovery plans and career goals. Enrollees who have
combat-related illness or injuries are concurrently enrolled in the
Air Force Wounded Warrior Program. For example, in fiscal year 2011,
almost 300 Air Force Recovery Care Program enrollees were also either
tracked or actively assisted by the Air Force Wounded Warrior Program.
(See table 9.)
Table 8: Air Force Wounded Warrior Program Enrollment Populations and
Characteristics, Fiscal Years 2008 through 2011:
Program enrollment for Air Force Wounded Warrior Program:
Total enrollment[A];
Fiscal year:
2008: 194;
2009: 451;
2010: 836;
2011: 1,386.
Servicemembers;
Fiscal year:
2008: 160;
2009: 388;
2010: 703;
2011: 1,143.
Active Duty;
Fiscal year:
2008: 103;
2009: 256;
2010: 463;
2011: 783.
National Guard;
Fiscal year:
2008: 32;
2009: 60;
2010: 123;
2011: 194.
Reservists;
Fiscal year:
2008: 25;
2009: 72;
2010: 117;
2011: 166.
Veterans;
Fiscal year:
2008: 34;
2009: 63;
2010: 133;
2011: 243.
Population characteristics:
Enrollees with combat-related conditions;
Fiscal year:
2008: 187;
2009: 442;
2010: 804;
2011: 1,327.
Enrollees with non-combat-related conditions;
Fiscal year:
2008: 7;
2009: 9;
2010: 32;
2011: 59.
Enrollees who changed duty status or left the program:
Returned to active duty;
Fiscal year:
2008: 4;
2009: 22;
2010: 65;
2011: 128.
Transitioned to veteran status;
Fiscal year:
2008: 157;
2009: 329;
2010: 532;
2011: 786.
Referrals and assists:
Total number of servicemembers referred to the program;
Fiscal year:
2008: 146;
2009: 357;
2010: 724;
2011: 1,176.
Servicemembers referred and enrolled in the program;
Fiscal year:
2008: 145;
2009: 337;
2010: 645;
2011: 1,071.
Servicemembers referred and assisted, but not enrolled in the
program[B];
Fiscal year:
2008: 1;
2009: 20;
2010: 79;
2011: 105.
Servicemembers referred but not enrolled in or assisted by the program;
Fiscal year:
2008: 0;
2009: 0;
2010: 0;
2011: 0.
Total number of veterans referred to the program;
Fiscal year: 2008:
34;
2009: 63;
2010: 133;
2011: 243.
Veterans referred and enrolled in the program;
Fiscal year:
2008: 34;
2009: 63;
2010: 133;
2011: 243.
Veterans referred and assisted, but not enrolled in the program;
Fiscal
year:
2008: NA;
2009: NA;
2010: NA;
2011: NA.
Veterans referred but not enrolled in or assisted by the program;
Fiscal year:
2008: 0;
2009: 0;
2010: 0;
2011: 0.
Legend: NA indicates that no data are applicable to the program.
Source: GAO analysis of Air Force Wounded Warrior Program data.
[A] Servicemembers may be dually enrolled in the Air Force Recovery
Care Program and the Air Force Wounded Warrior Program. The enrollment
data presented here only reflect servicemembers who are enrolled in
the Air Force Wounded Warrior Program.
[B] According to Air Force Wounded Warrior Program officials, because
the program only serves servicemembers with combat-related conditions,
most referrals come from casualty reports and the disability
evaluation process, where it is determined whether a servicemember's
wound, illness, and injury are combat-related. Once the determination
is made, servicemembers are enrolled into the program.
[End of table]
Table 9: Air Force Recovery Care Program Enrollment Populations and
Characteristics, Fiscal Years 2008 through 2011:
Program enrollment for Air Force Recovery Care Program:
Total enrollment[A];
Fiscal year: 2008: ND;
2009: ND;
2010: ND;
2011: 1,804.
Servicemembers;
Fiscal year:
2008: ND;
2009: ND;
2010: ND;
2011: ND.
National Guard;
Fiscal year:
2008: ND;
2009: ND;
2010: ND;
2011: ND.
Reservists;
Fiscal year:
2008: ND;
2009: ND;
2010: ND;
2011: ND.
Veterans;
Fiscal year:
2008: ND;
2009: ND;
2010: ND;
2011: ND.
Others[B];
Fiscal year:
2008: ND;
2009: ND;
2010: ND;
2011: 251.
Population characteristics:
Enrollees with combat-related conditions;
Fiscal year:
2008: ND;
2009: ND;
2010: ND;
2011: 316.
Enrollees with non-combat-related conditions;
Fiscal year:
2008: ND;
2009: ND;
2010: ND;
2011: 782.
Enrollees who changed duty status or left the program:
Returned to active duty;
Fiscal year:
2008: ND;
2009: ND;
2010: ND;
2011: 288.
Transitioned to veteran status;
Fiscal year:
2008: ND;
2009: ND;
2010: ND;
2011: 394.
Left for other reasons;
Fiscal year:
2008: ND;
2009: ND;
2010: ND;
2011: ND.
Referrals and assists:
Total number of servicemembers referred to the program;
Fiscal year:
2008: ND;
2009: ND;
2010: ND;
2011: 1,804.
Legend: ND indicates that no data are available.
Source: GAO analysis of Air Force Recovery Care Program data.
Notes: According to Air Force Recovery Care Program officials, the
program did not routinely track certain data about the program,
because these data were not required to be collected by the DOD policy
that governs the program. In addition, the original Air Force Recovery
Care program requirements did not include provisions for data
collection. The officials told us that a data-collection tool is being
developed and that requirements for data collection would be finalized
by the beginning of July 2012. The officials anticipate the new tool
will be operational by January 2013.
[A] Enrollees may also be enrolled in the Air Force's Wounded Warrior
Program.
[B] The Air Force Recovery Care Program serves some servicemembers
from other military services.
[End of table]
Marine Corps Wounded Warrior Regiment:
The Marine Corps established the Wounded Warrior Regiment in May 2007
to provide and facilitate assistance to wounded, ill, and injured
Marines and their family members throughout the recovery process. The
Wounded Warrior Regiment is a single command that oversees nonmedical
care for the total Marine force, including Active Duty, Reserve,
retired, and veteran Marines. The regiment enrolls Marines regardless
of whether they have combat-or non-combat-related conditions. The
regiment commands the operation of two wounded warrior battalions and
14 detachments located at 12 principal military treatment facilities
and four Veterans Affairs polytrauma medical centers across the United
States and overseas. A Marine enrolled in the regiment can either stay
with his or her parent unit and be supported by the regiment, or be
assigned or attached to one of the regiment's battalions and
detachments, depending on their specific needs. Generally, Marines who
require more than 90 days of medical treatment or rehabilitation are
assigned or attached to a battalion or detachment. The District
Injured Support Cells Program is the component of the Wounded Warrior
Regiment that provides services to veterans.[Footnote 78] District
Injured Support Coordinators are located at 30 sites across the United
States to provide support, including nonmedical care management to its
enrollees. In fiscal year 2011, the District Injured Support
Coordinators provided support to 1,488 veterans. (See table 10.)
Table 10: Marine Corps Wounded Warrior Regiment Enrollment Populations
and Characteristics, Fiscal Years 2008 through 2011:
Program enrollment for Marine Wounded Warrior Regiment:
Total enrollment[A,B];
Fiscal year:
2008: 810;
2009: 725;
2010: 634;
2011: 2,155.
Servicemembers;
Fiscal year:
2008: 810;
2009: 725;
2010: 634;
2011: 667.
Active Duty;
Fiscal year:
2008: 712;
2009: 633;
2010: 494;
2011: 517.
Reservists;
Fiscal year:
2008: 98;
2009: 92;
2010: 140;
2011: 150.
Veterans served through District Injured Support Coordinators[C];
Fiscal year:
2008: ND;
2009: ND;
2010: ND;
2011: 1,488.
Population characteristics:
Enrollees with combat-related conditions[D];
Fiscal year:
2008: 216;
2009: 105;
2010: 115;
2011: 224.
Enrollees with non-combat-related conditions[E];
Fiscal year:
2008: 594;
2009: 620;
2010: 519;
2011: 443.
Enrollees who changed duty status or left the program:
Returned to active duty;
Fiscal year:
2008: 35;
2009: 38;
2010: 84;
2011: 94.
Transitioned to veteran status;
Fiscal year:
2008: 149;
2009: 266;
2010: 311;
2011: 366.
Left for other reasons[E];
Fiscal year:
2008: ND;
2009: ND;
2010: ND;
2011: ND.
Referrals:
Total number of servicemembers referred to the program[F];
Fiscal year:
2008: ND;
2009: ND;
2010: ND;
2011: ND.
Total number of veterans referred to District Injured Support
Coordinators[G];
Fiscal year:
2008: ND;
2009: ND;
2010: ND;
2011: ND.
Legend: ND indicates that no data are available.
Source: GAO analysis of Marine Wounded Warrior Regiment data.
[A] According to a Wounded Warrior Regiment official, the Wounded
Warrior Regiment does not have "enrollees," rather the program assigns
and attaches Marines to the program.
[B] Total enrollment does not include Wounded Warrior Regiment
enrollees who are not assigned or attached to a Wounded Warrior
Regiment site. Many wounded, ill, and injured Marines are supported by
the Wounded Warrior Regiment while remaining with their parent unit.
[C] The District Injured Support Coordinators provide outreach and
services to Reserve and veteran Marines located across the country.
[D] The data in this category do not include Marines attached to the
Wounded Warrior Regiment who may have been wounded, fallen ill, or
injured in a combat zone, but who were not medically evacuated from a
combat zone.
[E] Although the Wounded Warrior Regiment was not able to provide data
on the number of enrollees who left the Wounded Warrior Regiment for
reasons other than returning to duty or transitioning to veteran
status, according to a Wounded Warrior Regiment official, Marines
attached to the Wounded Warrior Regiment have left the program for
other reasons such as death or as a result of military legal actions
taken against the Marine.
[F] According to a Marine Corps Wounded Warrior Regiment official,
although a policy exists requiring referral information to be
collected, the policy was not always enforced. According to this
official, as of fiscal year 2012, the data are routinely collected.
[G] According to a Marine Corps Wounded Warrior Regiment official, the
District Injured Support Coordinators initially served veterans on an
ad hoc basis, so referral information was not collected.
[End of table]
United States Special Operations Command's Care Coalition:
The United States Special Operations Command established the Care
Coalition in August 2005 to track, support, and advocate for Special
Operations Force's wounded, ill, and injured servicemembers regardless
of their duty status or whether their conditions are combat-related.
(See table 11.) All enrollees are assigned an Advocate and are
entitled to advocate services for life. Advocates assist enrollees
with health care and financial benefits, transition processes, and
link enrollees with needed government and nongovernment resources.
Because the United States Special Operations Command's Care Coalition
serves servicemembers from across the military services, it serves as
a liaison with, and complements, the military services' wounded
warrior programs. United States Special Operations Command's Care
Coalition enrollees are often concurrently enrolled in their own
military service's wounded warrior program. However, according to a
Care Coalition official, the Care Coalition serves as the lead program
for case management and care coordination for dually enrolled
servicemembers.
Table 11: United States Special Operations Command's Care Coalition
Enrollment Populations and Characteristics, Fiscal Years 2008 through
2011:
Program enrollment for United States Special Operations Command's Care
Coalition:
Total enrollment[A];
Fiscal year:
2008: 2,277[B];
2009: 2,532[B];
2010: 3,447;
2011: 4,570.
Servicemembers;
Fiscal year:
2008: 1,594;
2009: 1,741;
2010: 2,475;
2011: 3,518.
National Guard;
Fiscal year:
2008: 113;
2009: 127;
2010: 154;
2011: 228.
Reservists;
Fiscal year:
2008: 193;
2009: 196;
2010: 206;
2011: 232.
Veterans;
Fiscal year:
2008: 654;
2009: 722;
2010: 838;
2011: 893.
Others[C];
Fiscal year:
2008: 152;
2009: 192;
2010: 262;
2011: 287.
Population characteristics:
Enrollees with combat-related conditions[D];
Fiscal year:
2008: 1,693;
2009: 1,803;
2010: 2,415;
2011: 2,879.
Enrollees with non-combat-related conditions[D];
Fiscal year:
2008: 736;
2009: 839;
2010: 1,256;
2011: 1,859.
Enrollees who changed duty status:
Returned to active duty[E];
Fiscal year:
2008: 31;
2009: 32;
2010: 38;
2011: 46.
Transitioned to veteran status[E];
Fiscal year:
2008: 4;
2009: 23;
2010: 24;
2011: 48.
Referrals:
Total number of servicemembers referred to the program[F];
Fiscal year:
2008: ND;
2009: ND;
2010: ND;
2011: ND.
Total number of veterans referred to the program[F];
Fiscal year:
2008: ND;
2009: ND;
2010: ND;
2011: ND.
Legend: ND indicates that no data are available.
Source: GAO analysis of United States Special Operations Command's
Care Coalition data.
[A] Enrollees of the United States Special Operations Command's Care
Coalition Recovery Program may also be enrolled in a military
service's wounded warrior program on the basis of their branch of
service, but the United States Special Operations Command's Care
Coalition Recovery Program takes the lead for providing nonclinical
case management.
[B] According to a United States Special Operations Command's Care
Coalition official, because of a change in the data system used to
track enrollment, enrollment numbers provided for fiscal year 2008
include enrollees served by the program between October 1, 2007, and
May 28, 2009. Enrollment numbers provided for fiscal year 2009 include
an additional 255 servicemembers and veterans who enrolled in the
program between May 28, 2009, and September 30, 2009.
[C] Others enrolled include civilians, surviving family members, and
records with unknown information. According to a United States Special
Operations Command's Care Coalition official, the program continues to
provide and track services to surviving family members after an
enrolled servicemember or veteran has died.
[D] According to a United States Special Operations Command's Care
Coalition official, data provided on enrollees with either combat-or
non-combat-related conditions also include some servicemembers who
were either killed in action or died while enrolled in the program,
and therefore were excluded from the total enrollment data. In
addition, officials stated that the exact count for non-combat-related
conditions may not be accurate, due to inaccuracies in record keeping.
[E] According to a United States Special Operations Command's Care
Coalition official, the program did not begin tracking enrollee
transition status and transition dates in an accessible format until
January 2012. Therefore, information about the duty status and
transition status is being updated by hand as an individual record is
reviewed by program personnel, and the information provided may not be
accurate.
[F] According to a United States Special Operations Command's Care
Coalition official, the program has several methods of receiving
referrals, but its primary source of referrals comes from casualty
reports. The program does not track referral information because the
Care Coalition does not have a field in its database to track this
information. However, this official said that the Care Coalition could
access this information by contacting the military services.
[End of table]
VA Case Management and Care Coordination Programs:
VA operates a number of case management and care coordination programs
that provide assistance to recovering servicemembers and veterans,
including the Operation Enduring Freedom/Operation Iraqi Freedom/
Operation New Dawn (OEF/OIF/OND) Care Management Program and the
Federal Recovery Coordination Program (FRCP).[Footnote 79] These two
programs assist wounded servicemembers and veterans to navigate the
recovery care continuum.
OEF/OIF/OND Care Management Program:
The OEF/OIF/OND Care Management Program was established in March 2007
to provide case management to wounded, ill, and injured servicemembers
and veterans who screen positive for the need for case management or
request case management services. (See table 12). Each of VA's 152
Medical Centers (VAMC) has an OEF/OIF/OND Care Management team in
place to manage patient care activities and ensure that servicemembers
and veterans are receiving patient-centered, integrated care and
benefits. Members of the OEF/OIF/OND Care Management team include: a
Program Manager, Clinical Case Managers, and a Transition Patient
Advocate.
Table 12: Operation Enduring Freedom/Operation Iraqi Freedom/
Operation New Dawn (OEF/OIF/OND) Care Management Program Enrollment
Populations and Characteristics, Fiscal Years 2008 through 2011:
Total enrollment[B];
Fiscal year:
2008[A]: 2,463;
2009[A]: 7,048;
2010: 49,145;
2011: 50,255.
Servicemembers[C];
Fiscal year:
2008[A]: 152;
2009[A]: 590;
2010: 2,069;
2011: 2,505.
Veterans;
Fiscal year:
2008[A]: 1,136;
2009[A]: 4,212;
2010: 31,831;
2011: 29,848.
Others[D];
Fiscal year:
2008[A]: 1,175;
2009[A]: 2,246;
2010: 15,245;
2011: 17,902.
Population characteristics:
Enrollees with combat-related conditions[E];
Fiscal year:
2008[A]: 1,214;
2009[A]: 2,470;
2010: 7,165;
2011: 6,898.
Enrollees with non-combat-related conditions[F];
Fiscal year:
2008[A]: 212;
2009[A]: 676;
2010: 3,115;
2011: 3,188.
Enrollees with conditions not classified as either combat-or non-
combat-related[G];
Fiscal year:
2008[A]: 200;
2009[A]: 880;
2010: 4,820;
2011: 4,072.
Referrals:
Total number of servicemembers and veterans referred to the program by
military treatment facilities[H];
Fiscal year:
2008[A]: 2,130;
2009[A]: 4,474;
2010: 7,172;
2011: 6,686.
Source: GAO analysis of OEF/OIF/OND Care Management Program data.
[A] According to OEF/OIF/OND Care Management Program officials, 2008
and 2009 data only include severely wounded, ill, and injured because
the database only tracked this subpopulation of the program, which was
the initial focus of the program's efforts. This population included,
for example, those with severe burns, amputations, spinal cord
injuries, or blindness, or more than one of these. Soon after the
program was initiated, the Department of Veterans Affairs found that
people returning from the conflicts in Iraq and Afghanistan required
additional support, regardless of the severity of their injuries or
illnesses. Therefore, policy was changed and the OEF/OIF/OND Care
Management Program began tracking data on all those receiving case
management services through their program.
[B] Total enrollment includes those who serve or served in National
Guard and Reserve Components.
[C] The OEF/OIF/OND Care Management Program primarily serves veterans.
Some servicemembers who are receiving treatment through a VA facility
may also be enrolled in the program.
[D] Others include enrollees with unknown military status.
[E] Includes enrollees with battle injuries. According to OEF/OIF/OND
Care Management Program officials, battle injuries are injuries
sustained while in combat, such as a wound from an improvised
explosive device.
[F] Includes enrollees with nonbattle injuries. According to OEF/OIF/
OND Care Management Program officials, nonbattle injuries can include
injuries sustained in a combat zone that are not directly related to
combat.
[G] Includes enrollees with illnesses that may be classified as either
combat-related or non-combat-related. According to OEF/OIF/OND Care
Management Program officials, the program tracks whether an enrollee's
condition is a battle injury or a nonbattle injury, but not whether an
illness is related to combat.
[H] According to OEF/OIF/OND Care Management Program officials,
servicemembers and veterans are either referred to the program by a
military treatment facility or are screened into the program when a
servicemember or veteran initially seeks VA services at a VA treatment
facility.
[End of table]
FRCP:
The FRCP was established in January 2008. Developed as a joint program
by DOD and VA, but administered by VA, the program was designed to
provide care coordination services to servicemembers and veterans who
were "severely" wounded, ill, and injured after September 11, 2001.
(See table 13.) The program uses federal recovery coordinators to
monitor and coordinate clinical services, including facilitating and
coordinating medical appointments, and nonclinical services, such as
providing assistance with obtaining financial benefits or special
accommodations, needed by program enrollees and their families.
Federal recovery coordinators serve as the single point of contact
among all of the case managers of DOD, VA, and other governmental and
private case management programs that provide services directly to
servicemembers and veterans.
Table 13: Federal Recovery Coordination Program (FRCP) Enrollment
Populations and Characteristics, Fiscal Years 2008 through 2011:
Program enrollment for the FRCP:
Total enrollment;
Fiscal year:
2008: 177;
2009: 522;
2010: 823;
2011: 1,022.
Servicemembers;
Fiscal year:
2008: 132;
2009: 325;
2010: 394;
2011: 573.
National Guard[A];
Fiscal year:
2008: 11;
2009: 51;
2010: 84;
2011: 87.
Reservists[A];
Fiscal year:
2008: 7;
2009: 30;
2010: 45;
2011: 63.
Veterans;
Fiscal year:
2008: 43;
2009: 194;
2010: 429;
2011: 449.
Others;
Fiscal year:
2008: 2;
2009: 3;
2010: 0;
2011: 0.
Population characteristics:
Enrollees with combat-related conditions;
Fiscal year:
2008: ND;
2009: ND;
2010: ND;
2011: ND.
Enrollees with non-combat-related conditions;
Fiscal year:
2008: ND;
2009: ND;
2010: ND;
2011: ND.
Enrollees with conditions not classified as either combat-or non-
combat-related;
Fiscal year:
2008: ND;
2009: ND;
2010: ND;
2011: ND.
Referrals and assists:
Total number of servicemembers referred to the program;
Fiscal year:
2008: 179;
2009: 257;
2010: 268;
2011: 362.
Servicemembers referred and enrolled in the program;
Fiscal year:
2008: 132;
2009: 194;
2010: 222;
2011: 293.
Servicemembers referred and assisted, but not enrolled in the program;
Fiscal year:
2008: ND;
2009: ND;
2010: ND;
2011: ND.
Servicemembers referred but not enrolled in or assisted by the program;
Fiscal year:
2008: 47;
2009: 63;
2010: 46;
2011: 68.
Total number of veterans referred to the program;
Fiscal year:
2008: 44;
2009: 171;
2010: 165;
2011: 119.
Veterans referred and enrolled in the program;
Fiscal year:
2008: 43;
2009: 155;
2010: 150;
2011: 66.
Veterans referred and assisted, but not enrolled in the program;
Fiscal year:
2008: ND;
2009: ND;
2010: ND;
2011: ND.
Veterans referred but not enrolled in or assisted by the program;
Fiscal year:
2008: 1;
2009: 16;
2010: 15;
2011: 53.
Legend: ND indicates that no data are available.
Source: GAO analysis of FRCP data.
[A] According to an FRCP official, the total number of servicemembers
who are active duty cannot be delineated because the National Guard
and Reservist numbers are descriptive data points and do not designate
whether the enrollee is active duty or veteran. In addition, not all
National Guard and Reservists are included in the data due to database
limitations that have since been resolved.
[End of table]
Referral Information Tracked by DOD and VA Case Management and Care
Coordination Programs:
DOD and VA case management and care coordination programs primarily
identify servicemembers and veterans who may be eligible for
enrollment through referrals. Tracking referral information, including
the number of those who were referred and enrolled or not enrolled in
the program, may indicate whether the programs are identifying those
who could benefit from their services. However, fewer than half of the
DOD and VA case management and care coordination programs that we
reviewed track this type of referral information. (See table 14.)
Table 14: Referral Information Routinely Tracked by DOD and VA Case
Management and Care Coordination Programs:
Army:
Program: Army Warrior Care and Transition Program: Warrior Transition
Units and Community-Based Warrior Transition Units;
Referral information routinely tracked: [Check];
Types of referral information tracked, if any: Referral sources for
program enrollees.
Program: Army Warrior Care and Transition Program: Army Wounded Warrior
Program;
Referral information routinely tracked: [Check];
Types of referral information tracked, if any: Total number of
referrals made to the program; Number of those referred to the program
who were enrolled into the program; Number of those referred to the
program who were enrolled and provided short-term assistance by the
program, but who were later found ineligible for the program and
disenrolled; Number of those referred to the program who were not
enrolled into the program.
Navy/Coast Guard:
Program: Navy Safe Harbor Program;
Referral information routinely tracked: [Check][A];
Types of referral information tracked, if any: Total
number of referrals made to the program; Number of those referred to
the program who were enrolled into the program; Number of those
referred to the program who were provided short-term assistance by the
program, but not enrolled; Number of those referred to the program who
were not enrolled into the program or provided short-term assistance by
the program.
Air Force:
Program: Air Force Wounded Warrior Program;
Referral information routinely tracked: [Empty];
Types of referral information tracked, if any: According to Air Force
Wounded Warrior Program officials, since the program only serves
servicemembers with combat-related conditions, all referrals come
directly from the disability evaluation process, where it is
determined whether a servicemember's wound, illness, or injury is
combat-related.
Program: Air Force Recovery Care Program;
Referral information routinely tracked: [Empty];
Types of referral information tracked, if any: None.
Marines Corps:
Program: Marine Wounded Warrior Regiment;
Referral information routinely tracked: [Empty];
Types of referral information tracked, if any: According to a Marine
Wounded Warrior Regiment official, although a policy exists requiring
referral information to be collected, the policy was not always
enforced.[B]
United States Special Operations Command:
Program: United States Special Operations Command's Care Coalition;
Referral information routinely tracked: [Empty];
Types of referral information tracked, if any: According to a United
States Special Operations Command's Care Coalition official, the
program does not track referral information because there is no field
in its database to track this information. However, according to this
official, the program is able to access this information from the
individual military services.
Department of Veterans Affairs:
Program: Operation Enduring Freedom/Operation Iraqi Freedom/Operation
New Dawn Care Management Program;
Referral information routinely tracked: [Check];
Types of referral information tracked, if any: Total number of
referrals made to the program from military treatment facilities.
Program: Federal Recovery Coordination Program;
Referral information routinely tracked: [Check];
Types of referral information tracked, if any: Total number of
referrals made to the program; Number of those referred to the program
who were enrolled into the program; Number of those referred to the
program who were provided short-term assistance by the program, but
not enrolled; Number of those referred to the program who are not
enrolled into the program or provided short-term assistance by the
program.
Source: GAO analysis of DOD and VA data.
[A] According to a Navy Safe Harbor Program official, the database
used to track referral information did not capture accurate data until
it was upgraded in 2010.
[B] According to a Marine Corps Wounded Warrior Program official, as
of fiscal year 2012, data on referral information are routinely
collected.
[End of table]
[End of section]
Appendix II: Medical Category Assignment Process for Care Coordination
Programs:
The Senior Oversight Committee intended for the Federal Recovery
Coordination Program (FRCP) and the Recovery Coordination Program
(RCP) to be complementary programs, specifically identifying which
population of wounded, ill, and injured servicemembers would be
assigned to the two programs. On the basis of work done for the
committee, the Department of Defense (DOD) sent a report to
congressional committees in 2008 outlining a medical category
assignment process based on the severity of each servicemember's
medical condition, along with input from the servicemember and his or
her unit commander, to determine whether servicemembers would be
directed either to the FRCP or to the RCP programs for care
coordination services.
In concept, the medical category assignment process would have
resulted in wounded, injured, or ill servicemembers being assigned to
one of three categories. Servicemembers designated as Category 1 were
those who were found to have mild injury or illness, who were expected
to return to duty in less than 180 days of medical treatment, and
primarily received local outpatient and short-term inpatient treatment
and rehabilitation. Servicemembers designated as Category 2 were those
with serious injury or illness, who were unlikely to return to duty in
less than 180 days, and may be medically separated from the military.
[Footnote 80] Servicemembers designated as Category 3 were those with
severe injury or illness, who were highly unlikely to return to duty,
and were most likely to be medically separated from the military. The
category designation was intended to be used to determine whether the
recovering servicemember was subsequently referred to a care
coordination program, in that Category 1 servicemembers would not be
referred to a care coordination program, unless their medical or
psychological conditions worsen; Category 2 servicemembers would be
referred to the RCP; and Category 3 servicemembers would be referred
to the FRCP. (See figure 3.)
Figure 3: The Department of Defense's Vision of the Assignment Process
for the Recovery Coordination Program and the Federal Recovery
Coordination Program:
[Refer to PDF for image: illustration]
Note: In this figure, solid arrows indicate typical or expected results
and dashed arrows indicate alternative, but possible, outcomes.
Recovery:
Recovering Servicemember:
solid arrow connecting to:
Military Treatment Facilities;
Veterans Affairs Medical Centers;
Private Medical Facilities.
Rehabilitation:
Category 1 (mild);
solid arrow connecting from Military Treatment Facilities;
solid arrow connecting to: Multidisciplinary Team.
Category 2 (serious);
solid arrow connecting from Veterans Affairs Medical Centers;
solid arrow connecting to: Recovery Coordination Program.
Category 3 (severe);
solid arrow connecting from Private Medical Facilities;
solid arrow connecting to: Federal Recovery Coordination Program.
From Rehabilitation to Reintegration:
Multidisciplinary Team:
solid arrow connecting to: Fit;
dashed arrow connecting to: Not fit.
Recovery Coordination Program:
solid arrows connecting to: Fit; Not fit.
Federal Recovery Coordination Program:
solid arrow connecting to: Not fit;
dashed arrow connecting to: Fit.
Reintegration:
Fit:
solid arrow connecting to: Return to Duty.
Not fit:
solid arrow connecting to: Civilian Life.
Source: GAO analysis of Senior Oversight Committee data.
Note: In this figure, solid arrows indicate typical or expected
results and dashed arrows indicate alternative, but possible, outcomes.
[End of figure]
[End of section]
Appendix III: Comments from the Department of Defense:
The Assistant Secretary of Defense:
Health Affairs:
1200 Defense Pentagon:
Washington, DC 20301-1200:
October 23, 2012:
Mr. Randall B. Williamson:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Mr. Williamson:
This is the Department of Defense's (DoD) response to the Government
Accountability Office (GAO) Draft Report, GAO-13-5, "Recovering
Servicemembers And Veterans: Sustained Leadership Attention and
Systematic Oversight Needed to Resolve Persistent Problems Affecting
Care and Benefits," dated September 11, 2012 (GAO Code 20934). Thank
you for the opportunity to review the draft report.
The report makes specific recommendations to DoD. We offer the
enclosed comments and suggestions to make the report more technically
accurate; also attached are the responses to the two recommendations.
The points of contact are Ms. Sandra Mason (Functional) and Mr.
Gunther Zimmerman (Audit Liaison). Ms. Mason may be reached at (703)
428-7630, or Sandra.Mason@osd.mil. Mr. Zimmerman may be reached at
(703) 681-4350, or Gunther.Zimmerman@tma.osd.mil.
Sincerely,
Signed by:
Jonathan Woodson, M.D.
Enclosures:
1. Overall Comments.
GAO Draft Report Dated September 11, 2012:
GAO-13-5 (GAO CODE 290934):
"Recovering Servicemembers And Veterans: Sustained Leadership
Attention And Systematic Oversight Needed To Resolve Persistent
Problems Affecting Care And Benefits"
Department Of Defense Comments To The GAO Recommendation:
Recommendation 1:
* The GAO recommends that the Secretary of Defense establish or
designate an office to centrally oversee and monitor the activities of
the military Services' Wounded Warrior Programs to include the
following:
DoD Response: DoD concurs.
— The Under Secretary of Defense for Personnel and Readiness has the
authority to establish policies affecting Service Members and Wounded
Warrior disability matters and to direct the services to comply with
such policies. The Deputy Assistant Secretary of Defense for Warrior
Care Policy is the executive office for policy and oversight of Wounded
Warrior matters, including the Military Services' Wounded Warrior
Programs.
* Developing consistent eligibility criteria to ensure that similarly
situated recovering Service members from different military Services
have uniform access to these programs.
DoD Response: DoD partially concurs.
— In their 2011 report, the Recovering Warrior Task Force recommended
"Enforce the existing policy guidance regarding transition unit
entrance criteria." In our response to that recommendation, we noted,
"There is no DoD policy on the establishment of transition units and
entrance criteria. These policies have been established by the
Secretaries of the Military Departments for their specific
populations."
- The Department continues to believe that the three Service Secretaries
should control and maintain entrance criteria in to their transition
units (Wounded Warrior units.) This flexibility is both important and
necessary and we do not believe results in noticeable differences in
access to programs by the Wounded or their families.
— The Department agrees that the Services need to effectively
communicate the current eligibility criteria and to ensure that they
are delivering consistent programs to their eligible wounded, ill, and
injured Service Members.
* Direct the military Services' Wounded Warrior Programs to fully
comply with the policies governing care coordination and case
management programs and any future changes to these policies.
DoD Response: DoD concurs:
— The cornerstone document governing the Recovery Coordination
Program is DOD! 1300.24. It was published in December 2009 and it
outlines expected standards across the continuum of care. DoD will
take further steps to ensure that Wounded Warrior Programs are in
compliance with this doctrine, The Warrior Care Policy office will
reinstitute evaluation and compliance oversight to ensure adherence
with policies as outlined using a multiple source approach,
specifically staff assistance visits, interviews, and documentation.
* Develop a common mechanism to systematically monitor the performance
of the Wounded Warrior Programs-to include the establishment of common
terms and definitions-and report this information on a biannual basis
to the Armed Services Committees of the House of Representatives and
the Senate.
DoD Response: DoD partially concurs:
— The Interagency Care and Coordination Committee (IC3) will conduct
an inventory of all Wounded Warrior programs to identify duplication
and areas for gaining efficiencies. The Department reports progress in
these areas via the 3EC Annual Report, which is provided to the
Congress and the public annually. The Department believes additional
reporting to be redundant and of limited value.
— The Department agrees that the Services have defined the wounded, ill,
and injured populations in varied ways. Wherever possible, the
Department has instituted common definitions and terms relating to our
wounded, ill, and injured populations. Many of these common terms were
published by the Wounded, Ill, and Injured Senior Oversight
Committee in 2008. Many more were codified and defined in the
Recovery Care Coordination Instruction from 2009. We will continue to
review these terms and make any necessary policy adjustments as
necessary. We will also work towards driving all in this community to a
common understanding and use of these approved definitions.
Recommendation 2:
* The GAO recommends that the Secretaries of Defense and Veterans
Affairs ensure that these issues receive sustained leadership
attention and collaboration at the highest levels with a singular
focus on what is best for the individual Service member or Veteran to
ensure continuity of care and a seamless transition from the DoD to VA.
DoD Response: DoD concurs:
— For the past five years, joint DoD-VA priorities were overseen by two
different governance bodies, the Joint Executive Committee (JEC) and
the Senior Oversight Committee (SOC). On January 19, 2012, the
Departments agreed to consolidate the SOC and JEC forums, based on a
recommendation from DoD's Recovering Warrior Task Force. Both
Departments feel that the JEC provides the appropriate high level
exposure for the critical issues facing the wounded, ill, and injured.
— DoD and VA leaders are actively involved in the development of joint
policy decisions, timely implementation and oversight. To provide
sustained senior leadership attention and systematic oversight for
issues involving recovering Service members and Veterans, the
Secretaries of Defense and Veterans Affairs rely on the Co-Chairs of
the JEC, the Deputy Secretary of VA and the Under Secretary of Defense
for Personnel and Readiness to drive progress on joint issues.
— The purpose of merging the SOC and JEC forums was to ensure that all
Wounded Warrior care and benefit issues received the same level of
senior leadership attention as the rest of DoD and VA's collaborative
efforts, including an annual report to Congress and comprehenSive Joint
Strategic Planning process. In addition, the JEC relies on its sub
councils and working groups, such as the Health Executive Council and
Benefits Executive Council, within the JEC structure to provide the
subject matter expertise to implement leadership's direction.
— Since the consolidation, the frequency of JEC meetings increased
from quarterly to hi-monthly and now receives strategic and specific
direction from the Secretary of Defense and Secretary of Veterans
Affairs, who meet quarterly to discuss and oversee issues facing both
Departments. A few of the items that are now receiving the highest
levels of attention at the Secretary-level are: the transitioning of
our Service members to civilian life; the Disability Evaluation
System; Electronic Health Records; VA disability claims backlog; and
care coordination for recovering Service members.
This should include holding the Joint Executive Council accountable
for the following:
* Ensuring that key issues affecting recovering Service members and
Veterans get sufficient consideration. including recommendations made
by the Warrior Care and Coordination Task Force and Recovering
Warrior"Cask Force.
DoD Response: DoD concurs:
— The Warrior Care and Coordination Task Force was created by the JEC
in the summer of 2012 to develop recommendations for a more
synchronized process to deliver care, benefits, and services to
wounded, ill, and injured Warriors, Veterans and their families. At
the 27 Sep 2012 JEC, the co-chairs approved the transition of the Task
Force to the Interagency Care and Coordination Committee (IC3),
establishing formal governance structure that reports directly to the
JEC and which is responsible for implementing the recommendations of
the Task Force.
— With the consolidation of the Senior Oversight Committee with the
Joint Executive Committee, the Wounded, all and Injured Committee
(WIIC) was specifically created to focus on issues impacting wounded,
ill and injured Service members. The WIIC will report their progress
to the Joint Executive Committee (JEC), as does the Health Executive
Committee (HEC), the Benefits Executive Committee (BEC) and the
Interagency Care and Coordination Committee (IC3). Additionally, each
of the subgroups provides updates on the Joint Strategic Plan goals
and objectives. For instance the IC3 is defining and standardizing the
roles and responsibilities of care coordinators in addition to
standardizing and providing oversight on the Comprehensive Recovery
Plan/Comprehensive Transition Plan. This was specifically briefed to
the JEC at the September 27, 2012 meeting.
— The Departments have taken a similar and effective approach with
regards to the Recovering Warrior Task Force (RWTF) recommendations.
The Department has implemented 8 of the 21 recommendations made by the
RWTF in its FY2011 report and continues to work the remaining 13
recommendations. In the FY2012 report, the RWTF made 35
recommendations.
* Developing mechanisms for making joint policy decisions. involving
the appropriate decision makers for timely implementation of policy.
DoD Response: DoD concurs:
— The DoD and VA make joint policy decisions via the JEC on matters
affecting both departments. Since the consolidation with the SOC, the
frequency of JEC meetings increased from quarterly to bimonthly and
now receives specific strategic direction from the Secretary of
Defense and Secretary of Veterans Affairs, who meet quarterly to
discuss and oversee issues which face both Departments.
* Establishing mechanisms to systematically oversee joint initiatives
and ensure that outcomes and goals are identified and achieved.
DoD Response: DoD concurs:
— The overarching purpose of the consolidation of the SOC into the JEC,
is to make the JEC accountable for all key issues affecting recovering
Service members and to ensure the senior DoD and VA leaders are
involved in the development of policy decisions, as well as timely
implementation and oversight of related actions. The DoDNA Joint
Strategic Plan and JEC Annual Report identify interagency goals and
accomplishments to all stakeholders.
[End of section]
Appendix IV: Comments from the Department of Veterans Affairs:
Department of Veterans Affairs:
Washington DC 20420:
44. October 16, 2012:
Mr. Randall B. Williamson:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Mr. Williamson:
The Department of Veterans Affairs (VA) in close coordination with the
Department of Defense (DoD), has reviewed the Government
Accountability Offices (GAO) draft report, "Recovering Servicemen7bers
And Veterans: Sustained Leadership Attention and Systematic Oversight
Needed to Resolve Persistent Problems Affecting Care and Benefits"
(GAO-13-5). VA concurs with GAO's specific recommendation to the
Department. We agree with GAO that resolving the challenges facing
recovering Servicemembers and Veterans is a leadership issue.
VA and DoD have collaborated intensively on improving care
coordination. We appreciated your team's understanding of the dynamic
issues surrounding this topic and their openness to a joint exit
brief. As you can appreciate, these not only support our common
interests, but are a visual display that both our staffs are serious
about collaboration and integration.
Despite this concurrence with the report, the Departments are
concerned with the overall analysis and conclusions reached by GAO. In
particular, much of the report's conclusions lead to an over-
simplified portrayal of the recovery care continuum in place for the
transition of recovering Servicemembers and Veterans. Simply put, the
challenges the Departments face are broader and more complex than the
two programs the report focuses on, namely the Federal Recovery
Coordination Program (FRCP) and the Recovery Coordination Program
(RCP).
Last spring, VA and DoD, including Administration and Service level
leaders, initiated a task force to take a more detailed look at how we
execute case management and care coordination within and between the
two Departments. Formed in May 2012, this task force was co-chaired by
VA's Chief of Staff, and Principal Deputy Assistant Secretary of
Defense, Health Affairs.
We reviewed previous internal and external studies on Warrior care
programs including the series of GAO audits and reports on Wounded
Warrior care coordination and case management as well as materials
created by other high level task force efforts. One prevailing theme
we identified in these previous efforts was the need to better
integrate and synchronize delivery of DoD and VA care, benefits, and
services to the population of Warriors we are privileged to serve.
As you too have noted, there are thousands of dedicated and
exceptional military personnel, civil servants, and contractors
providing vital clinical and non-clinical case management and care
coordination services to Warriors and their families — people who need
the substantial services that both Departments provide. These caring
professionals strive to provide patient-centric care and services and
timely delivery of benefits; they attend to the needs of families; and
they work tirelessly to ensure the interests of their Warriors are
met. Across the Departments, we identified over 40 programs that
provide some level of coordination/management of care, benefits, and
services across the continuum of recovery. Today, there is no common
operational picture that facilitates collaborative planning and
assists all to achieve situational awareness. In summary, DoD and VA
recognize the challenge is more broad and deep than overlap of FRCP
and RCPs and those receiving their services; we must address this
across the Departments for all vital contributors to this important
work.
On September 27, 2012, the DoDNA Joint Executive Council (JEC)
received the second of two briefings from this task force. Based upon
the recommendation of the task force, the JEC created an Interagency
Care and Coordination Committee, reporting to the JEC, responsible for
developing interagency guidance that will drive DoD and VA policy.
This governing body will provide policy and oversight to a community
of practice composed of the programs with a role in executing the
transitioning Warrior's comprehensive plan. The comprehensive plan
will be patient/family-centric and will help the care coordinators and
case managers manage a Servicemember/Veteran's goals for recovery,
rehabilitation, and reintegration.
To maintain momentum and purpose, all of the task force leaders are
transitioning into positions in the newly established formal
governance structure. These leaders have begun working on a series of
immediate, near-term, and long-term recommendations to correct
perceived redundancies, and establish a model for the Nation in the
coordination of care for ill and injured individuals. Ultimately, this
effort is expected to create a long-term, sustainable model for the
two Departments.
The essential challenge we are now organized to address is the
comprehensive overhaul of the care coordination process to meet the
needs of today's recovering Warrior. We intend to address all of the
providers who work to manage and coordinate the delivery of care,
benefits, and services to this population. We must improve
communications and support to field personnel. There are opportunities
to improve and simplify the process to ensure services are neither
duplicated, nor erroneously eliminated, We recognize that we must be
clear to our patients and families, and to the team of care
coordinators and case managers, as to who has the lead.
The enclosure specifically addresses one of the GAO recommendations
and provides comments on the draft report. VA urges full incorporation
of the recommended changes.
VA appreciates your continued interest in the coordination and
management of care, service and benefits of our recovering
Servicemembers and Veterans and the opportunity to comment on your
draft report.
Sincerely,
Signed by:
John R. Gingrich:
Chief of Staff:
Enclosure:
Department of Veterans Affairs (VA) Comments to Government
Accountability Office (GAO) Draft Report "Recovering Servicemembers
And Veterans: Sustained Leadership Attention and Systematic Oversight
Needed to Resolve Persistent Problems Affecting Care and Benefits"
(GA0-13-5):
GAO Recommendation: To ensure that persistent challenges with care
coordination, disability evaluation, and the electronic sharing of
health records are fully resolved, we recommend that the Secretaries
of Defense and Veterans Affairs ensure that these issues receive
sustained leadership. attention and collaboration at the highest
levels with a singular focus on what is best for the individual
servicemember or veteran to ensure continuity of care and a seamless
transition from DOD to VA. This should include holding the Joint
Executive Committee (JEC) accountable for:
* ensuring that key issues affecting recovering servicemembers and
veterans get sufficient consideration, including recommendations made
by the Warrior Care and Coordination Task Force and the Recovering
Warrior Task Force,
* developing mechanisms for making joint policy decisions,
* involving the appropriate decision-makers for timely implementation
of policy, and,
* establishing mechanisms to systematically oversee joint initiatives
and ensure that outcomes and goals are identified and achieved.
VA Response: Concur. VA and DoD have mechanisms currently in place to
systematically oversee issues of joint interest such as the
recommendations made by the DOD-VA Warrior Care and Coordination Task
Force and relevant joint recommendations of the DoD Recovering Warrior
Task Force. There are several layers of oversight currently built into
the VA-DoD governance structure that includes: quarterly meetings of
the VA and DoD Secretaries; bimonthly meetings of the Joint Executive
Committee (JEC); and the regular meetings of the Health Executive
Committee (NEC); Interagency Care and Coordination Committee (IC3);
the Benefits Executive Committee (BEC); the Interagency Program Office
(IPO); and the Independent Working Groups (IWG). The Secretaries of VA
and DoD are committed to ensuring that key wounded, ill, and injured
issues such as care coordination, disability evaluation, and the
electronic sharing of health records receive sustained leadership
attention. To work the details and drive progress on these joint
issues, the Secretaries rely on the co-chairs of the JEC, the Deputy
Secretary of VA and the Under Secretary of Defense for Personnel and
Readiness. In addition, the JEC relies on the HEC, BEC, IPO, IC3 and
the IWG within the JEC structure to provide the subject matter
expertise to implement leadership's direction.
The JEC has mechanisms in place for making joint decisions and
regularly makes joint policy decisions that are initially developed by
the FIEG, BEC, IPO, 1C3, IWG, and brought to the JEC for resolution
and decisions. The co-chairs of the JEC work closely together to
provide leadership for VA-DoD governance. Since its consolidation with
the Senior Oversight Committee (SOC) in January 2012, the membership
of the JEC was enhanced to include key decision-makers from VA, DoD,
and the Services. This high level of leadership participation in JEC
meetings helps to ensure that key issues including those affecting
recovering Servicemembers and Veterans receive sufficient leadership
attention.
The JEC has mechanisms in place to systematically oversee joint
initiatives and to ensure outcomes and goals are identified and
achieved. The JEC establishes goals and objectives with identified
outcome oriented performance metrics in the VA/DoD
Joint Strategic Plan (JSP). The JSP documents key objectives from all
the organizations within the JEC governance structure, including the
HEC, BEC, IPO, IC3, and IWGs. (Note: JEC IWGs include the Construction
Planning Committee, Strategic Communications Working Group, Separation
Health Assessment Working Group, and the Wounded III and Injured
Committee.) In addition to the JSP, the JEC co-chairs also distribute
additional written guidance for each fiscal year designed to ensure
all JEC stakeholders are aware of joint priorities and objectives. At
the end of each fiscal year, the JEC assesses the progress made
towards reaching its goals as reported in the VA/DoD JEC Annual Report
to Congress. The JEC also continually evaluates progress and drives
outcomes in its bimonthly meetings.
The JEC is supported by the efforts of the HEC, BEC, 1P0, 1C3, and
IWGs, which all meet on a bimonthly or more frequent basis to
facilitate collaboration and progress at the subject matter expert
level. The HEC, BEC, IPO, and IC3 each have multiple sub working
groups that maintain regular VA-DoD collaboration and communication on
key issues at the staff level. This formal structure within the JEC
helps to organize and maintain leadership attention on the wide range
of VA-DoD issues. The co-chairs of the HEC, BEC, IPO, IC3, and IWGs
are responsible for identifying and raising to the JEC any issues
under their oversight that require higher level attention.
Additional Comments:
Page 14, "Recovering Servicemembers Are Not Always Identified and
Referred to Programs that May Benefit From Them" section: It is DoD
and/or VA treatment teams that determine when the Servicemember and
family are medically and psychologically ready to begin the transition
process. VA Operation Enduring Freedom (OEF)/Operation Iraqi Freedom
(01F)/Operation New Dawn (OND) clinical case managers screen all
returning combat Veterans for the need for case management services.
Page 26, 2nd paragraph, line 5: GAO states that according to a DoD
source, historically the JEC has not been able to drive policy
decision-making, and therefore issues that should have been decided by
the JEC were taken directly to the Secretaries for resolution.
VA Response: It is unclear as to what decisions GAO is referring that
have been taken directly to the Secretaries. It is true that since
February 2011, the Secretaries of DoD and VA have met 10 times. In
reality, these meeting have served to reinforce VA-DoD collaboration
efforts and to show their support for ongoing policy issues being
worked by the JEC. With the exception of the decision to create an
integrated VA-DoD electronic health record (iEHR), the Secretaries
have deferred joint policy decisions to the JEC.
Page 27, line 7: GAO states that it is unclear how the JEC will
provide oversight and accountability for issues once addressed by the
SOC.
VA Response: Resolution and tracking of former SOC issues such as
Integrated Disability Evaluation System (IDES), Integrated Mental
Health Strategy, Care Coordination, iEHR, and Virtual Lifetime
Electronic Records implementation, and Wounded, Ill, and Injured
Strategic Communications are now being actively tracked and reviewed
by the JEC leadership.
Page 38, 1st paragraph: The size of the overlap in the Federal
Recovery Coordination Program (FRCP)/Recovery Coordination Program
(RCP) population is fairly small, we need to look more broadly at the
overall DoD and VA Wounded, Ill, and Injured population that could
benefit from care coordination.
Page 39, 2sd bullet, 15t sentence: This is an inaccurate and
misleading statement.
Requested change: VA asked DoD to defer discussion of care
coordination and case management policy issues during this period of
time, because VA had established...."
[End of section]
Appendix V: GAO Contact and Staff Acknowledgments:
GAO Contact:
Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov:
Staff Acknowledgments:
In addition to the contact name above, Bonnie Anderson, Assistant
Director; Mark Bird, Assistant Director; Michele Grgich, Assistant
Director; Jennie Apter; Frederick Caison; Heather Collins; Dan
Concepcion; Melissa Jaynes; Deitra Lee; Mariel Lifshitz; Lisa Motley;
Elise Pressma; and Greg Whitney made key contributions to this report.
[End of section]
Related GAO Products:
Military Disability System: Improved Monitoring Needed to Better Track
and Manage Performance. [hyperlink,
http://www.gao.gov/products/GAO-12-676]. Washington, D.C.: August 28,
2012.
Military Disability System: Preliminary Observations on Efforts to
Improve Performance. [hyperlink,
http://www.gao.gov/products/GAO-12-718T]. Washington, D.C.: May 23,
2012.
More Efficient and Effective Government: Opportunities to Reduce
Duplication, Overlap and Fragmentation, Achieve Savings, and Enhance
Revenue. [hyperlink, http://www.gao.gov/products/GAO-12-449T].
Washington, D.C.: February 28, 2012.
2012 Annual Report: Opportunities to Reduce Duplication, Overlap and
Fragmentation, Achieve Savings, and Enhance Revenue. [hyperlink,
http://www.gao.gov/products/GAO-12-342SP]. Washington, D.C.: February
28, 2012.
DOD and VA Health Care: Action Needed to Strengthen Integration across
Care Coordination and Case Management Programs. [hyperlink,
http://www.gao.gov/products/GAO-12-129T]. Washington, D.C.: October 6,
2011.
VA and DOD Health Care: First Federal Health Care Center Established,
but Implementation Concerns Need to Be Addressed. [hyperlink,
http://www.gao.gov/products/GAO-11-570]. Washington, D.C.: July 19,
2011.
Federal Recovery Coordination Program: Enrollment, Staffing, and Care
Coordination Pose Significant Challenges. [hyperlink,
http://www.gao.gov/products/GAO-11-572T]. Washington, D.C.: May 13,
2011.
Information Technology: Department of Veterans Affairs Faces Ongoing
Management Challenges. [hyperlink,
http://www.gao.gov/products/GAO-11-663T]. Washington, D.C.: May 11,
2011.
Military and Veterans Disability System: Worldwide Deployment of
Integrated System Warrants Careful Monitoring. [hyperlink,
http://www.gao.gov/products/GAO-11-633T]. Washington, D.C.: May 4,
2011.
DOD and VA Health Care: Federal Recovery Coordination Program
Continues to Expand but Faces Significant Challenges. [hyperlink,
http://www.gao.gov/products/GAO-11-250]. Washington, D.C.: March 23,
2011.
Electronic Health Records: DOD and VA Should Remove Barriers and
Improve Efforts to Meet Their Common System Needs. [hyperlink,
http://www.gao.gov/products/GAO-11-265. Washington, D.C.: February 2,
2011.
Military and Veterans Disability System: Pilot Has Achieved Some
Goals, but Further Planning and Monitoring Needed. [hyperlink,
http://www.gao.gov/products/GAO-11-69]. Washington, D.C.: December 6,
2010.
Military and Veterans Disability System: Preliminary Observations on
Evaluation and Planned Expansion of DOD/VA Pilot. [hyperlink,
http://www.gao.gov/products/GAO-11-191T]. Washington, D.C.: November
18, 2010.
Electronic Health Records: DOD and VA Interoperability Efforts Are
Ongoing; Program Office Needs to Implement Recommended Improvements.
[hyperlink, http://www.gao.gov/products/GAO-10-332]. Washington, D.C.:
January 28, 2010.
Electronic Health Records: DOD and VA Efforts to Achieve Full
Interoperability Are Ongoing; Program Office Management Needs
Improvement. [hyperlink, http://www.gao.gov/products/GAO-09-775].
Washington, D.C.: July 28, 2009.
Recovering Servicemembers: DOD and VA Have Jointly Developed the
Majority of Required Policies but Challenges Remain. [hyperlink,
http://www.gao.gov/products/GAO-09-728]. Washington, D.C.: July 8,
2009.
Recovering Servicemembers: DOD and VA Have Made Progress to Jointly
Develop Required Policies but Additional Challenges Remain.
[hyperlink, http://www.gao.gov/products/GAO-09-540T]. Washington,
D.C.: April 29, 2009.
Army Health Care: Progress Made in Staffing and Monitoring Units that
Provide Outpatient Case Management, but Additional Steps Needed.
[hyperlink, http://www.gao.gov/products/GAO-09-357]. Washington, D.C.:
April 20, 2009.
Electronic Health Records: DOD's and VA's Sharing of Information Could
Benefit from Improved Management. [hyperlink,
http://www.gao.gov/products/GAO-09-268]. Washington, D.C.: January 28,
2009.
Electronic Health Records: DOD and VA Have Increased Their Sharing of
Health Information, but More Work Remains. [hyperlink,
http://www.gao.gov/products/GAO-08-954]. Washington, D.C.: July 28,
2008.
DOD and VA: Preliminary Observations on Efforts to Improve Care
Management and Disability Evaluations for Servicemembers. [hyperlink,
http://www.gao.gov/products/GAO-08-514T]. Washington, D.C.: February
27, 2008.
DOD and VA: Preliminary Observations on Efforts to Improve Health Care
and Disability Evaluations for Returning Servicemembers. [hyperlink,
http://www.gao.gov/products/GAO-07-1256T]. Washington, D.C.: September
26, 2007.
DOD and VA Health Care: Challenges Encountered by Injured
Servicemembers during Their Recovery Process. [hyperlink,
http://www.gao.gov/products/GAO-07-589T]. Washington, D.C.: March 5,
2007.
[End of section]
Footnotes:
[1] "Soldiers Face Neglect, Frustration at Army's Top Medical
Facility," Washington Post (Washington, D.C.: Feb. 18, 2007); "The
Other Walter Reed: The Hotel Aftermath," Washington Post (Washington,
D.C.: Feb. 19, 2007); and "Hospital Investigates Former Aid Chief,"
Washington Post (Washington, D.C.: Feb. 20, 2007).
[2] Independent Review Group, Rebuilding the Trust: Report on
Rehabilitative Care and Administrative Processes at Walter Reed Army
Medical Center and National Naval Medical Center (Arlington, Va.:
April 2007); Task Force on Returning Global War on Terror Heroes,
Report to the President (April 2007); President's Commission on Care
for America's Returning Wounded Warriors, Serve, Support, Simplify
(July 2007); Veterans' Disability Benefits Commission, Honoring the
Call to Duty: Veterans' Disability Benefits in the 21st Century
(October 2007); and Department of Defense Office of the Inspector
General, Department of Veterans Affairs Office of the Inspector
General, DOD/VA Care Transition Process for Service Members Injured in
OIF/OEF (June 2008).
[3] According to the Case Management Society of America, case
management is defined as a collaborative process of assessment,
planning, facilitation, and advocacy for options and services to meet
an individual's health needs through communication and available
resources to promote high quality, cost-effective outcomes.
[4] See list of related GAO products at the end of this report.
[5] In this report, we will use the term "recovering servicemembers"
to denote wounded, ill, and injured servicemembers.
[6] Pub. L. No. 110-181, § 1611, 122 Stat. 3, 433 (2008).
[7] National Defense Authorization Act for Fiscal Year 2010, Pub. L.
No. 111-84, § 724, 123 Stat. 2190, 2389 (2009).
[8] Department of Defense Task Force on the Care, Management, and
Transition of Recovering Wounded, Ill, and Injured Members of the
Armed Forces, Department of Defense Recovering Warrior Task Force 2010-
2011 Annual Report (September 2011).
[9] To understand how VA interacts with servicemembers, the Recovering
Warrior Task Force reviewed VA programs, including those that assist
servicemembers with the transition from DOD's to VA's health care
system.
[10] According to the National Coalition on Care Coordination, care
coordination is a client-centered, assessment-based interdisciplinary
approach to integrating health care and social support services in
which an individual's needs and preferences are assessed, a
comprehensive care plan is developed, and services are managed and
monitored by an identified care coordinator.
[11] See Hearing on the Federal Recovery Coordination Program: From
Concept to Reality, Subcommittee on Health, Committee on Veterans'
Affairs, House of Representatives (May 13, 2011); and Review of the VA
and DOD Integrated Disability Evaluation System, Hearing before the
Committee on Veterans' Affairs, United States Senate (Nov. 18, 2010).
[12] Pub. L. No. 110-181, § 1615(d), 122 Stat. 2, 447.
[13] GAO has produced a body of work assessing progress made to
improve care, management, and transition of recovering servicemembers,
including: Recovering Servicemembers: DOD and VA Have Made Progress to
Jointly Develop Required Polices but Additional Challenges Remain,
[hyperlink, http://www.gao.gov/products/GAO-09-540T] (Washington,
D.C.: Apr. 29, 2009); Recovering Servicemembers: DOD and VA Have
Jointly Developed the Majority of Required Policies but Challenges
Remain, [hyperlink, http://www.gao.gov/products/GAO-09-728]
(Washington, D.C.: July 8, 2009); DOD and VA Health Care: Federal
Recovery Coordination Program Continues to Expand but Faces
Significant Challenges, [hyperlink,
http://www.gao.gov/products/GAO-11-250] (Washington, D.C.: Mar. 23,
2011); DOD and VA Health Care: Action Needed to Strengthen Integration
across Care Coordination and Case Management Programs, [hyperlink,
http://www.gao.gov/products/GAO-12-129T] (Washington, D.C.: Oct. 6,
2011).
[14] We selected key care coordination and case management programs
that provide assistance to recovering servicemembers and veterans--
many of which were created or modified after Walter Reed media
reports. These programs have also been the subject of prior reviews by
GAO and others.
[15] See list of related GAO products.
[16] The terms "wounded, ill, and injured" are used by DOD and VA as
general classifications of servicemembers or veterans with regard to
their medical condition. "Wounded" generally means any injury
inflicted by an external force during combat. "Ill and injured" refers
to any illness or injury in the line of duty that may render the
servicemember medically unfit to perform the duties of his or her
office, grade, rank, or rating.
[17] President's Commission on Care for America's Returning Wounded
Warriors, Serve, Support, Simplify.
[18] OEF, which began in October 2001, supports combat operations in
Afghanistan and other locations, and OIF, which began in March 2003,
supports combat operations in Iraq and other locations. Since
September 1, 2010, OIF is referred to as Operation New Dawn (OND).
[19] Federal Recovery Coordinators are intended to coordinate all care
and benefits for their enrollees, including coordinating assistance
from private sector programs.
[20] Pub. L. No. 110-181, § 1635, 122 Stat. 3, 460-63.
[21] Interoperability is the ability of two or more systems or
components to exchange information and to use the information that has
been exchanged.
[22] Recovering servicemembers include those who are wounded, ill, or
injured in a combat zone or due to an incident that occurred in the
United States or overseas while in active status.
[23] According to a VA official, in fiscal year 2013, VA will hire 10
additional liaisons and expand the number of MTFs where liaisons will
be located to 21.
[24] The VA OEF/OIF/OND Care Management Program screens all returning
combat veterans to determine if case management services are required.
[25] Not all wounded, ill, and injured servicemembers and veterans are
eligible for access to these programs. Most military service wounded
warrior programs only serve those who are "seriously" and "severely"
wounded, ill, and injured.
[26] Casualty reports, including personnel casualty reports, are
electronic messages that contain casualty information including type
of injury, where the injury occurred, and location of the injured
servicemember.
[27] We found that referrals by unit command staff are most likely,
because they have the most knowledge about servicemembers' conditions,
injuries, and treatment locations.
[28] [hyperlink, http://www.gao.gov/products/GAO-11-250].
[29] Servicemembers are eligible for certain VA benefits while still
on active duty, including access to treatment at specialized VA
facilities and grants for home and car modifications.
[30] Operation Warfighter is a DOD-sponsored internship program for
wounded, ill, and injured servicemembers who are at MTFs. Operation
Warfighter is designed to provide recuperating servicemembers with
meaningful activity outside of the hospital environment that assists
in their wellness and offers a formal means of transition back to the
civilian workforce. Open to active duty, National Guard and Reserve
components, Operation Warfighter represents an opportunity for
servicemembers in a medical hold status to build their resumes,
explore employment interests, develop job skills, and gain valuable
work experience that will prepare them for the future [see hyperlink,
http://www.militaryhomefront.dod.mil].
[31] The Warrior Athlete Reconditioning program provides recreational
activities and competitive athletic opportunities to recovering
servicemembers to improve their physical and mental quality of life
throughout the continuum of recovery and transition. The program is
designed to enhance recovery by engaging recovering servicemembers in
physical and cognitive activities outside of traditional therapy
settings.
[32] Servicemembers do not have to be enrolled in or attached to a
wounded warrior program to participate in the VA Liaison for
Healthcare Program or the Warrior Athlete Reconditioning Program.
[33] Recovering Warrior Task Force, Department of Defense Recovering
Warrior Task Force 2010-2011 Annual Report.
[34] GAO, Military Disability System: Preliminary Observations on
Efforts to Improve Performance, [hyperlink,
http://www.gao.gov/products/GAO-12-718T] (Washington, D.C.: May 23,
2012). For additional information about IDES, see reports listed on
the related products page.
[35] The fiscal year 2008 and 2011 averages include only those
servicemembers who completed IDES and received VA benefits. The
averages do not include other outcomes, such as servicemembers who
were found fit and returned to duty. Not all reservists complete the
VA benefit phase and thus DOD does not apply the 30-day goal for this
phase to reservists. For those reservists who do go through the VA
benefits phase, this time is reflected in the overall time in IDES.
[36] As we have previously testified, other reasons that could impact
the increase in IDES processing times include large case loads and
insufficient staff to complete a stage of IDES in a timely manner.
[37] Department of Defense Office of the Inspector General, Special
Plans and Operations, Assessment of DOD Wounded Warrior Matters-Camp
Lejeune (March 2012) and Department of Defense Office of the Inspector
General, Special Plans and Operations, Assessment of DOD Wounded
Warrior Matters-Wounded Warrior Battalion-West Headquarters and
Southern California Units (August 2012).
[38] See, for example, GAO, Electronic Health Records: DOD and VA
Efforts to Achieve Full Interoperability Are Ongoing; Program Office
Management Needs Improvement, [hyperlink,
http://www.gao.gov/products/GAO-09-775] (Washington, D.C.: July 28,
2009); Electronic Health Records: DOD and VA Interoperability Efforts
Are Ongoing; Program Office Needs to Implement Recommended
Improvements, [hyperlink, http://www.gao.gov/products/GAO-10-332]
(Washington, D.C.: Jan. 28, 2010) and Electronic Health Records: DOD
and VA Should Remove Barriers and Improve Efforts to Meet Their Common
System Needs, [hyperlink, http://www.gao.gov/products/GAO-11-265]
(Washington, D.C.: Feb. 2, 2011).
[39] DOD policy requires that, upon retirement, discharge, or end of
active obligated service, records be transferred to the VA Records
Management Center if the servicemember is not applying for VA benefits
or the appropriate VA Regional Office if the servicemember has applied
or plans to apply for VA benefits. Department of Defense, Service
Treatment Record (STR) and Non-Service Treatment Record (NSTR) Life
Cycle Management, DOD Instruction 6040.45, Enclosure 3, (Oct. 28,
2010). The transfer of records from DOD to a VA medical facility is
achieved under different procedures.
[40] In 2008, DOD established the Office of Transition Policy and Care
Coordination which was renamed the Office of Wounded Warrior Care and
Transition Policy (WWCTP). Reporting to the Under Secretary of Defense
for Personnel and Readiness, up until June 2012, WWCTP served as a
single, centralized office for developing policy, coordinating
interagency collaboration, and conducting outreach to address the
broad set of issues confronted by wounded, ill and injured service
members and their families. WWCTP also provided program oversight for
the integrated disability evaluation system process and care
coordination.
[41] The Joint Executive Council was established by law in November
2003 to provide senior leadership for collaboration and resource
sharing between DOD and VA. Through a joint strategic planning
process, the Joint Executive Council recommends to the Secretaries the
strategic direction for the joint coordination and sharing efforts
between the two departments and oversees the implementation of those
efforts.
[42] With the change of presidential administration in January 2009,
the Deputy Secretary of Defense and Deputy Secretary of Veterans
Affairs were replaced.
[43] [hyperlink, http://www.gao.gov/products/GAO-09-728].
[44] Department of Defense Task Force on the Care, Management, and
Transition of Recovering Wounded, Ill, and Injured Members of the
Armed Forces, Department of Defense Recovering Warrior Task Force 2011-
2012 Annual Report (August 2012).
[45] Recovering Warrior Task Force, Department of Defense Recovering
Warrior Task Force 2011-2012 Annual Report.
[46] Department of Defense, Recovery Coordination Program, DOD
Instruction 1300.24, (Dec. 1, 2009).
[47] See GAO, Military and Veterans Disability System: Pilot Has
Achieved Some Goals, but Further Planning and Monitoring Needed,
[hyperlink, http://www.gao.gov/products/GAO-11-69] (Washington, D.C.:
Dec . 6, 2010); Military and Veterans Disability System: Worldwide
Deployment of Integrated System Warrants Careful Monitoring,
[hyperlink, http://www.gao.gov/products/GAO-11-633T] (Washington,
D.C.: May 4, 2011); and [hyperlink,
http://www.gao.gov/products/GAO-12-718T].
[48] See Pub. L. No. 111-84, § 906, 123 Stat. 2190, 2425 (2009).
[49] Recovering Warrior Task Force, Department of Defense Recovering
Warrior Task Force 2010-2011 Annual Report.
[50] Recovering Warrior Task Force, Department of Defense Recovering
Warrior Task Force 2011-2012 Annual Report.
[51] See [hyperlink, http://www.gao.gov/products/GAO-11-69];
[hyperlink, http://www.gao.gov/products/GAO-11-633T]; [hyperlink,
http://www.gao.gov/products/GAO-12-718T]; Electronic Health Records:
DOD and VA Have Increased Their Sharing of Health Information, but
More Work Remains, [hyperlink, http://www.gao.gov/products/GAO-08-954]
(Washington, D.C.: July 28, 2008); Electronic Health Records: DOD's
and VA's Sharing of Information Could Benefit from Improved
Management, [hyperlink, http://www.gao.gov/products/GAO-09-268]
(Washington, D.C.: Jan. 28, 2009); Information Technology: Challenges
Remain for VA's Sharing of Electronic Health Records with DOD,
[hyperlink, http://www.gao.gov/products/GAO-09-427T] (Washington,
D.C.: Mar. 12, 2009); [hyperlink,
http://www.gao.gov/products/GAO-09-775]; and [hyperlink,
http://www.gao.gov/products/GAO-10-332].
[52] [hyperlink, http://www.gao.gov/products/GAO-11-69].
[53] [hyperlink, http://www.gao.gov/products/GAO-12-718T].
[54] Veterans Opportunity to Work (VOW) to Hire Heroes Act, Pub. L.
No. 112-56, tit. II, 125 Stat. 712 (2011).
[55] GAO, Military System: Improved Monitoring Needed to Better Track
and Manage Performance. [hyperlink,
http://www.gao.gov/products/GAO-12-676] (Washington, D.C.: Aug. 28,
2012).
[56] See Pub. L. No. 110-181, § 1635, 122 Stat. 3, 460-63 (2008).
[57] Legislative Hearing on H.R. 2383, H.R. 2388, H.R. 2243 and H.R.
2470, Before the Subcommittee on Oversight and Investigations of the
Committee on Veterans Affairs, 112th Cong. (July 20, 2011) (statement
of Debra M. Filippi, former Director, U.S. Department of Defense/U.S.
Department of Veterans Affairs Interagency Program Office).
[58] As we reported in 2008, the Interagency Program Office was in the
process of recruiting about 30 permanent staff members [see hyperlink,
http://www.gao.gov/products/GAO-08-954].
[59] According to DOD and VA officials, the departments have
identified 54 joint capabilities that will be implemented by the end
of fiscal year 2017.
[60] [hyperlink, http://www.gao.gov/products/GAO-12-129T].
[61] The Recovery Warrior Task Force also reported that DOD has
partially addressed an additional 6 recommendations and noted that 13
recommendations remain open.
[62] Responding to a recommendation of a consulting firm that advised
VA on its care coordination and case management policy, the VA Chief
of Staff directed that VA conduct a department-wide inventory and
review of its existing care coordination and case management programs
and personnel.
[63] Communities of practice are groups of people who engage, through
regular interaction with one another, in a process of collective
learning in a shared domain of human endeavor.
[64] The Joint Executive Council meets on a bimonthly basis.
[65] [hyperlink, http://www.gao.gov/products/GAO-12-129T].
[66] According to the National Coalition on Care Coordination, care
coordination is a client-centered, assessment-based interdisciplinary
approach to integrating health care and social support services in
which an individual's needs and preferences are assessed, a
comprehensive care plan is developed, and services are managed and
monitored by an identified care coordinator.
[67] According to the Case Management Society of America, case
management is defined as a collaborative process of assessment,
planning, facilitation, and advocacy for options and services to meet
an individual's health needs through communication and available
resources to promote high quality, cost-effective outcomes.
[68] Military services operate multiple programs that are specialized
to serve different populations, such as the severely wounded or
surviving family members. For example, within the Air Force's Warrior
and Survivor Care Program, the Air Force operates three distinct
programs: (1) the Air Force Wounded Warrior Program to serve those who
were injured in combat; (2) the Air Force Recovery Care Program to
serve other seriously and severely wounded, ill, and injured; and (3)
the Air Force Survivor Assistance Program, to serve surviving family
members or caregivers of wounded, ill, and injured servicemembers.
[69] For the purpose of this appendix we will be discussing seven of
the case management and care coordination programs established by the
military services to assist recovering servicemembers and veterans
with recovery, rehabilitation, and transition either back to military
service or to civilian life.
[70] DOD defines command and control as the exercise of authority and
direction by a properly designated commander over assigned and
attached forces in the accomplishment of the mission.
[71] The program was originally named the Army Medical Action Plan.
[72] Warrior Transition Units are technically an Army brigade,
battalion, or company that provides command and control,
administrative support, primary care and case management and other
services to promote readiness of soldiers and family to transition
back to active duty or to civilian life. For the purposes of this
report, we are categorizing it as a wounded warrior program.
[73] The Community-based Warrior Transition Unit Program allows
servicemembers to live at home and perform duty at a location near
home while receiving medical care.
[74] Warrior transition units and community-based warrior transition
units serve Active Component servicemembers as well as servicemembers
in National Guard and Reserve Components, but do not serve veterans.
[75] The Army Wounded Warrior Program was originally named the
Disabled Soldier Support System.
[76] According to Navy Safe Harbor Program officials, the program
evolved from the Navy's preexisting Military Severely Injured Center &
Casualty Office.
[77] The Air Force Warrior and Survivor Care Program's Survivor
Assistance Program primarily provides services to the families of
wounded, ill, and injured servicemembers.
[78] District Injured Support Coordinators may also provide support to
Reserve and Active Duty Marines in remote locations away from military
or other federal resources.
[79] In addition, the Department of Veterans Affairs operates other
dedicated programs and systems of care including Polytrauma/Traumatic
Brain Injury, Spinal Cord Injury and Diseases, Visual Impairment, and
Mental Health that provide specialized lifelong clinical care and care
management for these special cohorts of veterans.
[80] DOD subsequently modified the 180-day criteria to "within a time
specified by his or her military department" to accommodate different
standards used by the Marine Corps and the Army.
[End of section]
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